What the Affordable Care Act means to you

My patients, colleagues, and friends still have many questions about the Affordable Care Act.  Multiple surveys show most Americans still do not understand many key details of the new law.  Since the Health Insurance Exchanges open tomorrow (October 1st), I am posting this summary from a colleague to shed some light on the subject.


Why bother?  Isn’t the government going to shut down and stop this?  Won’t Congress delay Obamacare anyway?

Even with a government shutdown, the exchanges will open as scheduled on Oct. 1. The money the federal government is using to run them doesn’t rely on appropriations from Congress. The Republican-controlled House of Representatives has deliberately linked the Affordable Care Act to the continuing resolution — the law that keeps the federal government funded. They want Democrats in Congress and President Obama to agree to delay or even repeal the law in return for keeping the government running. Not going to happen, say the Democrats and Obama. It’s far more likely that the government will shut down for a few days and then both sides will agree to keep cash flowing without bringing the health-reform law into it.

And it’s very unlikely the Republicans in Congress, who have vowed to repeal the health-reform law, can succeed; because all laws have to pass the Senate and Democrats who support the law control the Senate. And President Barack Obama would veto any such repeal, of course. Even some Republicans point out that the Supreme Court has ruled Obamacare constitutional and it is now the law of the land.

Got insurance already? You don’t need to worry

Most of us — 58 percent of non-elderly Americans — get health insurance through an employer, and 32% get government-sponsored insurance such as Medicare or Medicaid. The U.S. Census Department says about 15 percent of Americans don’t have health insurance and these are the people who should be either buying health insurance on the new exchanges, or getting it through Medicaid in the states that are offering it to more people.

The opening of the exchanges doesn’t affect anyone who already has insurance. The law does change some of the rules regarding health insurance, but the only thing happening Tuesday is the opening of the exchanges. Other changes go into effect Jan. 1.

Some news reports have highlighted the cases of employers who have decided their workers will be better off buying insurance on the exchanges. This may be because the federal subsidies would actually lower costs for them. If you have workplace-sponsored insurance, your employer must give you a letter detailing what your options are.

What are these exchanges?

The exchanges are a new way to buy health insurance<http://www.nbcnews.com/health/got-3-minutes-your-guide-new-health-markets-8C11287042> that let people compare the plans available to them and to also see, within minutes, whether the federal government will pay for part of the premiums. They’ve been compared to online sites such as Travelocity or Expedia, where people can compare the prices of airline flights across different carriers. At the same time, the sites check to make sure people are telling the truth about their income and employment.

How much will it cost?

The prices vary<http://www.nbcnews.com/health/5-things-know-about-obamacare-premiums-4B11214626> based on the different plans — a lot like employer-provided insurance works now. There are four tiers of coverage: bronze, silver, gold and platinum. The bronze plans usually charge lower premiums, but then you’ll be charged a higher co-pay, which means you pay each time you see a doctor or other provider, each time you fill a prescription, or each time you have a procedure. The platinum plans charge the highest premiums but provide much more care before the patient has to pay a share. In some places, young adults can also buy bare-bones catastrophic insurance for people who really think they’ll only need health care if they have an accident.

A lot depends on where you live. In some counties, a family of four with an income of $50,000 may pay $11 a month for a low-level silver plan. In other places a similar family might pay $280 a month for the same plan. This is because care costs more in different places. You can give the federal government site a run now at www.healthcare.gov<http://www.healthcare.gov/> although you cannot actually enroll until Tuesday.

Will the plans be expensive — more than plans cost now?

Some of the bare-bones plans are likely to cost more than the minimal-coverage plans on the market now, but that’s because you get much more coverage. Many of the plans available now don’t provide much coverage, and can stop paying for services once patients start running up bills. The Affordable Care Act requires insurers to provide a basic level of care, which includes free preventive services such as vaccines, mammograms and wellness checkups. They cannot cap your coverage and they can’t charge you more just because you are a woman, for instance.

Can people get help paying for the insurance?

Many people can get a federal government subsidy. It depends on how much you make<http://www.nbcnews.com/health/some-say-obamacares-affordable-coverage-isnt-affordable-them-4B11241833> and your family size, but the subsidies can be very generous. It’s a complicated formula but families with incomes of up to $94,000 might get a subsidy. There’s a calculator here<http://kff.org/interactive/subsidy-calculator/> that you can use to estimate what it might cost.

There’s a big exception <http://www.nbcnews.com/health/falling-through-cracks-if-states-dont-expand-medicaid-928243> for people who make very little money. The law assumed that states would expand Medicaid to cover people who earn less than 138 percent of the federal poverty level, which works out to $16,000 for an individual or $32,500 for a family of four. But the Supreme Court ruled that states don’t have to, and many states won’t. These people also don’t qualify for subsidies if they make less than the federal poverty level, and right now they are stuck. They’ll either have to pay full price on the exchanges, or go without insurance.

If your employer offers adequate insurance but you decide to go to the exchanges to buy some anyway, you can’t get a subsidy. But you may qualify for one if the insurance you have now isn’t adequate.

What if I don’t want to pay?

Technically, you’ll have to pay a fine<http://www.nbcnews.com/health/big-question-who-has-buy-health-insurance-4B11214274>, which varies depending on your income. The argument is that people without health insurance cost everyone money because they do get sick or hurt and they do go to emergency rooms and someone has to pay in the end. The Supreme Court says it’s a tax. The IRS can take the money out of any refund you have coming. In reality, it’s not clear how hard the federal government will go after holdouts.

What if I’m already sick?

That’s called a pre-existing condition. Right now, insurance companies can refuse to cover you if you’re sick, or they can refuse to pay for care for some condition, such as diabetes, if you had it before you bought insurance. Not any more. Now insurers have to cover everyone, regardless of their health or previous illnesses.

What about if people are too busy to sign up Oct. 1?

Tuesday’s just the first day that the exchanges are open for business. People have six months to sign up for health insurance during what’s called open enrollment. If you get signed up by Dec. 15, you can start using your insurance on Jan. 1, 2014.

So where do I go to get started?

Anyone can go online and sign up at https://www.healthcare.gov/. You can find a person or place to help you by entering your zip code here<https://www.healthcare.gov/blog/how-to-get-help-with-your-marketplace-application/>. States that are offering health insurance have their own sites, too, like Delaware<http://www.choosehealthde.com/Health-Insurance/Individuals-And-Families?gclid=CNitoaaI77kCFc01Qgods0YAgA> and California<http://www.coveredca.com/>. Various privately funded groups like Enroll America <http://www.enrollamerica.org/get-enrolled/how-to-enroll>  also have websites to help people sign up.

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Doctor bonuses lead to more blood pressure lowering than team bonuses

A recent randomized, controlled trial of the impact of incentive payments based on quality outcomes showed some expected – and unexpected results:

  • Individual physician bonuses increased % patients with controlled BP by 8.4%,
  • Practice-level bonuses increased % patients with controlled BP by 3.2%
  • Combined bonuses increased % patients with controlled BP by 5.5%

This study seems to contradict the hypothesis that team based care improves quality outcomes.  The newspaper article below discusses some reasons the team bonuses may have been less effective.  I think we can conclude that when physicians stand to gain directly from improved control of chronic disease measures, they will do more to meet those goals.


Petersen, Laura, et al “Effects of individual physician-level and practice level financial incentives on hypertensive care” JAMA 2013;310(10):1042-50. http://jama.jamanetwork.com/article.aspx?articleid=1737042


Houston study finds doctor bonuses produce better care

By Todd Ackerman

September 17, 2013

Patients fare better when their doctor receives a bonus for positive results, but they regress after the payment ends, according to a new study of the emerging movement to reward quality rather than quantity.

The study, conducted by Baylor College of Medicine researchers, found significant but not sustained improvement in the blood pressure of patients whose doctor got a modest financial incentive to produce better outcomes. Such incentives are an example of what’s known as “pay for performance,” a key component of health-care reform.

“Pay for performance isn’t a panacea for all that ails health care, but this study shows even modest incentives can be effective in improving care,” said Dr. Laura Petersen, a Baylor professor of medicine and the study’s principal investigator.”It isn’t the only answer, it’s not the sole intervention needed, but this study suggests incentives should be part of the package of reforms that can improve health care.”

Petersen said she was surprised study participants’ blood pressure backslid after the study ended, but didn’t draw the conclusion incentives need to be provided in perpetuity to work. She acknowledged, however, she had expected patients would have developed better habits and sustained improvement.

Also to Petersen’s surprise, the study found that patients did not fare better when the patient’s whole health-care team received incentives.

Petersen said she undertook the research, published in last week’s edition of the Journal of the American Medical Association, because health policy often is adopted because it sounds like a good idea, not because of rigorous scientific evidence in support of it.

Pay-for-performance emerged as one recommended solution to America’s overpriced, under-performing health-care system in the middle half of the previous decade. Health-care economists argued that a system that rewards outcomes would be less wasteful than the current fee-for-service system, whose reimbursement is based on the number of tests ordered or procedures performed.

Petersen, also associate chief of staff for research at Houston’s Michael E. DeBakey Veterans Affairs Medical Center, conducted the study at 12 VA hospital outpatient clinics in five different regions over a 15-month period in 2007 and 2008.

Four groups studied

Eighty-two doctors and 43 support staff members were split into four groups: one in which only the doctor received an incentive; one in which an incentive was split equally among a health-care team; one in which all members of the team received an incentive but the doctor’s was significantly more; and a control group in which there was no incentive.

The study found the incentive to doctors alone resulted in an 8.36 percent increase in patients whose blood pressure was reduced to desired levels or who received appropriate medical intervention when it became clear their high blood pressure couldn’t be lowered sufficiently without drugs. Petersen said the improvement was particularly impressive because blood pressure levels of VA patients nationally already are considered good.

There was not a statistically significant benefit to either of the teams that shared incentives.

The incentives averaged $1,648 when the teams shared equal amounts; $4,270 to the doctors and $1,181 to members of the team in the groups in which the money was unequally allocated; and $2,672 to doctors who alone got the bonus.

Petersen said the disappointing results from the incentivized teams may have been because the VA only made a priority of organizing home-care teams after the study. But Jim Rebitzer, a Boston University professor of management, said it is not uncommon for there to be problems with team incentives.

“The more people in a team, the more the incentive gets diluted, the greater the chances of someone free-riding,” said Rebitzer, who’s written extensively about incentive programs in and out of health care. “It’s not that they can’t work, but as we know from families, groups don’t automatically function at a high level.They take a lot of management.”

Limits to incentives

Rebitzer added that the regressions found after the study ended show the limits of pay-for-performance. He acknowledged that incentives can work well for discrete, specific targets.

He said that would mean spending more time on them and less on something else, something doctors find hard to manage, particularly given the number of conditions that require constant attention for sustained results.

The study was applauded as an important contribution to the field by Rebitzer, Rice University health economist Vivian Ho and Pauline Rosenau, a professor of management, policy and community health at the University of Texas School of Public Health in Houston.

But Rosenau added that “it is sad that health-care providers must be offered a relatively trivial financial incentive to do the job that they should be doing anyway.”

Rosenau added that “pay for performance is here to stay – and patients should know about it. They should ask their doctor if he or she is receiving a bonus and how it might affect their care.”

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Thoughts for the Jewish New Year from “Not Running a Hospital” by Paul Levy


Posted by Paul Levy in his blog “Not Running A Hospital”

Wise words from my friend Boaz Tamir

On this eve of the New Jewish Year, the fog grows thicker and the horizon seems to be moving ever-further away: We face uncertainty, confusion and daily challenges to our assessments of what the morrow may bring. Once our slogan was, “Every plan serves as a basis for change;” but the in the current pace of change, we must adopt a slogan of, “Changes are the basis for never-ending planning.”

The changes are multi-dimensional: technological innovations; global climate change, civil uprising and political unrest, drastic adjustments in public consciousness, consumer awareness and the political arena and the rearrangement of global and local systems are bringing about epic transformations. These are leading to a destabilization of the validity of established economic, political and managerial paradigms and their usefulness as a base for the development of economic-political polices and sustainable business strategies.

What should we wish for others and for ourselves as this New Year begins?

  1. That we learn to adjust to reality, even if we have no theory to explain it.
  2. That we learn to view chaos as a lever for creativity, disruption as an advantage and crisis as an opportunity.
  3. That we are wise enough to create systems that blur hierarchical boundaries, whose stability stems from constant movement in fluid surroundings.
  4. That we replace the paralyzing anxiety brought about by uncertainty with the ability to grow in a storm.
  5. That we exchange pride with modesty, answers with questions and certainty with investigation.
  6. That we succeed in integrating internal and external strengths as we enlist workers and managers to cope with an environment full of contradictions and disharmony.
  7. And to those who have lost their way in the fog: We hope that they will be able to return to their foundations – to interpersonal relations, the foundations of culture, and to be willing to learn from organizational frameworks and cultures that have survived for thousands of years.

Happy New Jewish Year,
Boaz Tamir, Zicheron Yaakov, September 5th, 2013

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What is a good doctor?

Although I missed the blockbuster 2011 Brad Pitt movie “Moneyball,” I recently read the book by Michael Lewis. Oakland A’s general manager Billy Beane, a promising high school prospect out of California, was drafted by the New York Mets the same year as Darryl Strawberry and Lenny Dykstra. Despite looking like a top prospect to the scouts, Beane’s major league career ended early while Strawberry and Dykstra won the 1986 World Series with the Mets. As the general manager of the Athletics, Beane struggled to define more accurately what makes a baseball player good. This got me thinking: How do I know I’m a good doctor?

I can point to the diplomas on my wall and tell you I went to good schools, but the U.S. News and World Report rankings are little more than opinion surveys with minimal hard data to back up their lists. I can show you a copy of my Texas medical license, but that just means I haven’t broken any laws nor received any complaints to the Texas Medical Board. You could look at my American Board of Family Medicine diploma, know that I have passed a national exam and do annual online education modules, and consequently assume I know something. You do not know, however, if I am better than the doctors across the street.

You could ask my patients. They would tell you I often run behind but they would recommend me to their friends over 90 percent of the time. They might say I am a good listener or helped them through a difficult time, but they will not know what my diabetic patients’ average hemoglobin A1C is. When the Kaiser Family Foundation asked people how they chose a doctor or hospital, the majority said they relied on the advice of friends and neighbors, not on published mortality and quality data.
You could ask Medicare. My Physician Quality Reporting System data says my diabetic patients’ average hemoglobin A1C is better than 75 percent of the doctors in the country, but fewer than half of my patients get their diabetic eye exams. How much of that is my fault and how much occurs because their eye doctors do not send a report back to me? I am still looking for the answer to that one.
You could ask the insurance companies, but their first priority is whether I take care of their customers—my patients—in a cost-effective manner. If I hit their HEDIS quality targets, they are even happier, mainly because they get a higher star rating to put in their marketing material to attract more customers. They value keeping their members out of the hospital and emergency room, and discharging them quickly because that lowers their costs, not because the quality of care is better.
You could ask the hospital where I am on staff. They can tell you if they have achieved their Joint Commission Core Measures, but not what role I play in meeting their targets. They can’t tell you if I have run afoul of their complaint driven quality review process, because that information is privileged. They will maintain that they have only the best doctors on staff, but you have to decide if you believe them.

The answer to the question of whether I am a good doctor depends on who is asking the question. Whether we love or hate the amount of information different entities collect about us, we have to gain control of this data so we can articulate our own definitions of quality and defend them with numbers. We do not have time to react indignantly as though our honor has been grievously insulted when someone questions the quality of our care. We must analyze our own data so we can answer affirmatively: Yes, I am a good doctor, and here is the data to back that up.

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United we stand, divided we fall

On a quiet Sunday morning recently, I ran through the Vicksburg National Military Park. The park road snakes along the Union and Confederate trench lines, winding up and down the bluffs above the Yazoo Mississippi Rivers. Blue and red metal plaques mark the Union and Confederate positions while marble headstones memorialize the units that fought here in 1863. Whomever controlled Vicksburg controlled the flow of goods to the Southern interior. After months of vicious battles and a bitter 47 day siege, the Rebel forces surrendered on July 4th, 1863. When the US government established the military park here, it invited each state to build a monument to its fallen soldiers.

As I crested a small hill, I saw the sign pointing towards the Kentucky memorial. I followed the trail as it led into the former no man’s land. In the center of the battlefield stood a large marble disk with statues of Abraham Lincoln and Jefferson Davis. Busts of Kentucky generals who fought for the North and the South stood on their respective sides of the disk. The names of Kentucky units which fought for the Union and Confederate causes were inscribed on the low marble wall. While Kentucky joined the Union cause, a secessionist government fought with the Confederacy. I did not know that both Lincoln and Davis were both born in Kentucky. The great national divisions which nearly rent our nation asunder ran right through the Blue Grass State.

As I reflect on the Trayvon Martin case in Florida, I think about the Kentucky Monument at Vicksburg. One hundred fifty years ago we fought a bloody civil war to settle the question of what it means to be an American. The ill-fated encounter between Trayvon Martin and George Zimmerman and the ensuing national controversy show how this question remains unanswered.

Perhaps the public outcry and protests show that while we still have not answered the question of race in our country, the Civil War did defend the process of civil discourse and debate enshrined in our Constitution. Rodney King asked “Why can’t we all get along?” Until we can, we are all obligated as citizens to discuss, debate, march, and protest, exercising our Constitutional freedoms to try to answer the question of what it means to be an American.

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Advocacy Lesson #1: Don’t Call a Senator a B*/#!

A witness testifying in support of a state innocence commission became upset when the chairwoman of the Criminal Justice Committee didn’t support the bill. Enraged, he called her a “bitch” and stormed out of the hearing room. I admire the gentleman’s passion for his cause, but think that his anger diminished his message.

This incident illustrates some principles I have learned during this legislative session:

1) Never lose your temper: No matter how angry you are, say “Thank you, ma’am” and come back next time. About 20 years ago, the CEO of a major US airlines called the chairman of the taxation committee a SOB as he walked out of the hearing. His reward was a tax increase on his airline.  You can agree to disagree then either martial more support for your cause or find common ground with your opponents.

2) Do your homework: Before you testify, look up what bills that legislator has filed in the current and earlier sessions.  Read the committee members’ profiles to learn what their background is and what type of work they do.  If many of these bills advocate for victims’ rights and tighten rules on the accused, then the legislator is less likely to support an innocence commission. If the legislator was an assistant DA and criminal court judge before election to the Senate, then she is unlikely to support your bill from the get go.

3) Public hearings do not make or break a bill: The legislature doesn’t work like the US Senate in Mr Smith Goes To Washington. I dream of making the great speech that will persuade everyone as to the rightness of my cause, but that is not how things really happen. Most of the work comes before the committee hearing. If you haven’t been talking to the committee members and their legislative aides for months by then and have a sense of where they stand, then you have not prepared correctly.

4) Do the electoral math: Does supporting your bill make electoral sense for that legislator? If voting for your bill will increase the change of drawing a primary opponent, ask how you can translate a yes vote into something that representative can run on or defend. For example, a conservative rural Republican can defend support for Medicaid expansion as a way to keep rural hospitals stay open.

5) Learn from your mistakes:  Even with the best preparation, you can lose a committee vote.  Legislation can die in many ways.  Be ready to come back again next session after drumming up support in the interim.

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“What A F%$!ing Joke!”

I knew I reached a new level in the blogosphere when I received my first comment with an F-bomb.  Given the author’s passion about the topic, I decided to respond.

What a fucking joke. Someone who in his own words, “rarely worked more than 80 hours a week” commenting on something he hardly knows anything about.

I appreciate your energy and the time you took to respond. My intent was to provoke discussion. Your vitriol, however, obscures your argument.

As to whether I am commenting on “something he hardly knows anything about;” for the first 7 years after I graduated from residency, I worked in a multispecialty group taking hospital call and delivering my own obstetrical patients, so I know something about patient care. For the last 7 years, I have served as faculty in family medicine residencies at a community health center and later a large urban hospital. I am currently president of my state specialty society and serve on the family medicine advisory committee to the state agency which distributes state funding to all Texas GME programs. I think I know a little about residency.

The point I was trying to make regarding my residency work weeks usually being less than 80 hour work weeks was that my residency was largely compliant with the intent of the current rules without the administrative burden of the regulations. I think the ACGME imposed a one size fits all solution that appears to be more needed in New York and Chicago than in rural North Carolina.

“80 hours a week of actual patient care is plenty. I don’t know where you did residency, but at least here in NYC where I am training and Chicago where I went to medical school (but to a less degree) some where on the order of 1/2 of the time spent in the hospital is spent doing non-medical administrative BS. Hospitals (ab)use residents as cheap labor; the issue isn’t 80 hours, it’s spending those 80 hours doing nonsense instead of making decisions. Learning how to call the lab 5x / day to get a test drawn or pestering the nurse / phlebotomist to draw labs is not something that I need training in.”
I agree that more of your time should be spent caring for patients and gathering needed experience.   When my residents worry they will get in trouble because they stay late to complete needed work on patients, then the rules need to be changed. I still feel that the IOM and ACGME impose regulations without adequately considering the unintended consequences on quality of patient care, continuity with patients, and patient safety from the work hour rules. Their approach is to mandate first, study later.

I’m sorry that you had to train in the “dark ages.” Fact is, you did family medicine and still didn’t push 80 hrs. If hospitals had their way, as they once did prior to the massive resident strike in the 60s (not sure about the date, may have been the 50s), Interns were literally in the hospital 24 hrs / day and were unpaid. Maybe we should go back to that?

Your point is a straw man. I am in no way advocating a return to the house officer of the 1950’s who lived in a dorm and was not allowed to marry. To assume that anyone who challenges the work hour rules wants to return to this antiquated structure is to use a cheap rhetorical device to disparage anyone who disagrees with you.

OR maybe we should regular WHAT residents do as well as HOW long they do it for.

Good point.

You’re right, life has no work house rules; you can choose to work more or less, but that’s up to you. If you want to work in a practice that makes you take call all the time you can do that and you’ll be compensated for it; OR you can work less and be compensated less. When you don’t have a choice, there have to rational limits, especially when your salary is being paid by the federal government.

I agree.  I want to make sure that future physicians are well-trained enough to handle the increasingly complex patients I have to manage now.  I see good family medicine residents not push themselves to the limits of their skill because they did not get enough experience during residency. I do not suggest 120 hour work weeks as the solution; but when you try to cram more training and teaching in to less time per week and a fixed residency duration, something has to be left out.

W/ regard to your Rural Medicine friend, I suspect two things have happened:
1. He thinks too much of himself and doesn’t remember how green he was when he first started. Its pretty common amongst mid-career physicians in their 40s and 50s.
2. The quality of the grads has decreased a bit from when he graduated, but not as much as he thinks. Why? While the intention of 80 hrs was to give residents some time off, that’s is not what actually happened; Let’s say for example in the typical 100 hr work week of a resident, 50% is spent on patient care and 50% is spent on administrative bs (in reality I would think it’s more like 10:90, but whatever). If you’re limited to 80 hrs, guess which 20% is going to get cut? The patient care.

Again, I think we can agree that training should focus more on patient care and less on administrative work.

I look forward to discussing this topic further and am glad I was able to stimulate some discussion.

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Four Things I Don’t Plan To Change

Here’s another great post from Waco family physician and friend Tim Martindale:

I hear constantly we are in a new world of medicine, and things cannot stay the same. We must make some adjustments, they say, to survive and cope in this new environment. Well I don’t want to be an ostrich with my head in the sand, and I am very involved with reading articles, attending meetings, and wrestling constantly with this new, changing world. I am active in my county medical society, my local specialty society, and my hospital staff. But there are some things the conventional wisdom says have to, or already have, changed, and I don’t agree.

1. I want to focus on listening to, looking at, and examining the patient. This affects decisions on how many patients I see, how to use my electronic medical record, and how I prioritize my time in the exam room. There is no substitute for the gestalt I get when I see, listen to, review history, examine the patient, then talk it over with them. So I see less numbers, find ways to not be boxed in or directed by my EMR, and make the patient my partner in their care.

2. I want to remain a patient advocate. Insurance, government, employers, drug companies, etc. all want me to consider their agendas, and put obstacles, checklists, prior authorizations, peer to peer reviews, endless paperwork, and threats of lower reimbursement or being branded as a lesser quality doc in my way. But my first priority is the health interests of my patient, and I’ll wade through all that nonsense tirelessly to meet that goal. My staff has the same vision and the perseverance of a bulldog.

3. I want to do complete, continuous, comprehensive, efficient care for my patient. I still do all my own hospital work, as well as nursing home and home visits. By doing this, I maintain the commitment to comprehensive and continuous care, the desire to be there for my patients at their most difficult times, the need for someone who knows the patient best to serve as the coordinator of care, the goal to keep my skills at maximum and not narrow my scope of practice, the pleasure and challenge of complicated hospital acute illness management, the camaraderie with the specialists as we work together, the desire to be a leader in hospital and community medical issues, and the widening of my knowledge base as I work with challenging cases alongside specialists. Yes, I do work harder, but I’m more happy and fulfilled. I should note that I respect physicians who have chosen otherwise, and hospitalists today are excellent.

4. I will continue to make my physical, emotional and spiritual health and wholeness a priority, as well as that of my physician partner and clinic staff. That means I think about it, plan for it, make sacrifices for it, and talk about it regularly with those alongside me. We can’t be victims of this relentless pressure and paperwork so that we push ourselves to the point of disqualification where we can no longer serve our communities in such a powerful way because we have forgotten about ourselves.

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So Simple A Child Could Do It: Slide Rules vs. iPads

Checking in at the dentist's office

Checking in at the dentist’s office


When we walked into the dentist’s office, my kids ran straight up to the computer to check in for their appointments.  This was my first time to take them to the dentist as my wife usually drives them.  My son and daughter quickly entered their names on the touch screen, grabbed books, and took their seats.  Freed from manually registering patients, the front desk clerk monitored patient flow and welcomed everyone to the clinic with freshly baked chocolate chip cookies.

Later that day, I went to my doctor’s office where I signed my name on a clipboard and patiently waiting in the lobby as patients have done for decades.  His office has the same electronic medical record as mine, but his clipboard system has not changed in decades.  My clinic has an EMR with a web portal and secure patient email, but our patients still queue at the front desk to give  their information to a clerk.  At the gas station, I swipe my credit card and fill my gas tank without talking to another human being.  At the airport, I walk up to the kiosk, insert a credit card, and print the boarding pass for the flight I checked in to the night before.  We expect businesses to adopt the latest customer service technology and embrace their use while we keep our clinics in the technological dark ages, suspiciously questioning each new innovation.  We complain about the inefficiencies of our electronic medical records but are slow to adopt innovations to improve the efficiency and ease of our patients’ visits to our offices.  Are we so focused on our frustrations that we forget our patients?

Some of this skepticism is well founded.  For the past four years I have used the same EMR software I helped implement in my residency fourteen years ago.  I can do work but do not save time.  It still cannot talk to the hospital system so I do not have to look up the results of lab tests drawn five miles away. Although the computer file format that allows EMRs to communicate with each other has existed for years, I just read another editorial this morning lamenting the lack of interoperability between competing software products.  While I firmly believe that such technology can improve patient care, these benefits are far from inevitable.  In the United States, we believe in the goodness of technology like an article of faith.  If you don’t think that technology will make your life better, you must be old-fashioned – or tragically unhip.  Too often, however, we fail to adequately question whether the benefits the vendor promised are as good as advertised.

In a recent discussion thread, colleagues compared the latest fitness apps for their smart phones and GPS-based devices.  I have tried similar devices but have found an “old-fashioned” running watch to be far more reliable.  While I enjoy my smart phone, tablet, and laptop, I think we must still channel our inner Luddite by asking:  Is this technology really improving our lives as much as we think?  Are there unintended consequences we will regret in years to come?

On the other hand, we shouldn’t simply disregard potential benefits based on such concerns.  If my children can check in to their own appointments, why don’t we make this available for all our patients?  If my 80-year-old can learn to use secure email to communicate with me, why can’t you?  If my 50-year-old on Coumadin can check his own INR at home, email me the results, and adjust his medicine based on my emailed response, why don’t more patients adopt this technology?

Learning to use the iPad


My father learned engineering with a slide rule, was one of the first to use the “revolutionary” Hewlett Packard desk top calculator, taught himself DOS and Windows a decade later, and now is mastering the iPad. While he is not sure he likes how the screen orientation changes when he turns the it, I doubt he would give up his iPad for a slide rule.  Such technological changes are inevitable, but our responsibility is to ensure they benefit our patients.

The genie is out of the bottle and it’s too late to put him back.

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How Does It Feel To Treat Someone Who Repulses You?

This post about the April 15th bombings at the Boston Marathon comes from Jerry Abraham, MPH, a 3rd year medical student at UT Health Science Center San Antonio.

“The real question is…How does it feels to treat someone who repulses you? Not just someone who annoys you—anyone training or working in healthcare in an urban area treats plenty of the very annoying: drug dealers, pimps, prostitutes, thieves, and thugs, as well as embezzlers, defrauders, money launderers, and inside traders. Rather, what is it like to treat someone whose very right to exist strikes a passionate chord?

Some health care workers may come to feel infuriated or morally wrong. A sense even may arise from some staff that they are abetting an enemy and are somehow complicit in his crime.

Of course they are not. Similar to the provisions of the Third Geneva Convention, which dictate that even the most heinous war criminal must receive humane treatment, every ill person must receive proper medical care. But this approach should not arise from the fact that it is our contractual duty under the law and we want to keep our job. Rather, providing drama-free, professional care even under extreme personal duress demonstrates our one priestly quality—our humanity, the single trait that distinguishes us from the person whose inhumane actions have caused so much sorrow.

The legal dilemma facing medical staff is clear: the Emergency Room is compelled to treat everyone who enters the doors in need of emergency care.

In 1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) to assure that patients in need of emergency treatment receive medically proper attention.

This law prevented patient dumping—the convenient refusal to care for the indigent demonstrated by certain hospitals looking for an exclusive, cash-and-carry clientele. Doctors and nurses, as employees of the hospital, have agreed to follow the hospital’s rules as a condition of employment.

In other words, though the issue of a morally objectionable patient has not specifically addressed, the law provides no room for personal choice—hospital staff must treat everyone—equally.”

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