Saturday, May 29, 2004

From Medical Economics: Jobs 2004: Primary care outlook . It seems that not all primary care is created equal, and general internists are benefiting:

The San Francisco Bay Area used to be an intensely competitive job market for physicians. But Douglas C. Tong, who recently graduated from an internal medicine residency program at UCLA, had no trouble finding a position there. He joined the Camino Medical Group, a multispecialty practice in Sunnyvale, after turning down an offer from Kaiser Permanente and interviewing with a number of other West Coast groups, including the Palo Alto Clinic.
Why was it so easy to find a position in an area that was saturated with physicians only a few years ago? Tong notes there's a large turnover of internists in the region, partly because of the high cost of living there. But the strong demand for general internists across the country points to other factors as well.
Of the 30 residents who graduated from UCLA's internal medicine program last year, about half went on to fellowships, five became hospitalists, and just 10 entered private practice. Those 10 were "highly recruited," notes Teresa Roth, house staff coordinator for the residency program. One reason, she says, is that the pool of internists going into primary care has diminished greatly in recent years as more and more doctors have chosen higher-paying specialties.

But this doesn't seem to apply as much to FP's looking for a job....

Physician recruiters say their clients—mostly hospitals and midsized and large group practices—are more interested in internists than in family physicians or pediatricians. According to Mark Smith, executive vice president of Merritt, Hawkins & Associates in Irving, TX, this is partly a byproduct of employers' current focus on recruiting specialists. "If you're having trouble recruiting cardiologists or can't afford them, you can recruit an internist to relieve some of the demand for cardiology."......

In contrast, large multispecialty groups are reportedly reluctant to hire family doctors. "We see groups who are interested in having higher-end primary care physicians—the ob/gyns and the general internists, not the FPs," says Steve Messinger, a practice management consultant in Arlington, VA. "It's because the value they bring to the practice is much higher: There's more spinoff of ancillary revenue and referrals to the surgeons."

There isn't a similar situation going on with surgeons that I'm aware of for mainly two reasons, there are fewer surgeons overall and given the longer "sentence" of a surgery residency there is more "training fatigue" than may be seen in an internal medicine program. The desire to do a fellowship certainly waned for me as my training progressed.

I did learn today while 1250 pounds of sand is a pain to load and spread, doesn't go very far.

Friday, May 28, 2004


Hospitals suffer so we don't have to

Since free registration is required, here it is:

Last week, our 16-month-old son hit his head, had a seizure, and stopped breathing for several minutes. It was the most terrifying experience of our lives. 911. Ambulance. Emergency room. Tests and scans, all normal. A cautious release. Two days later, another massive seizure. Another terrifying ambulance ride, watching my unconscious baby under a tiny oxygen mask. This time, they admitted him.

The hospital -- Children's Healthcare of Atlanta at Scottish Rite -- was wonderful, the medical staff knowledgeable and compassionate, the care terrific. It wasn't until halfway through this experience, when things were under control and it was clear our son was OK, that I looked around and started to wonder: Aren't hospitals in financial crisis? How are they doing this? Is Children's just flush with cash, while all other hospitals suffer?

Turns out, no. Children's faces the same serious problems as all other hospitals, but as a patient, you'd never know it. In fact, you'd never know it at most of the hospitals you go to, not just in Georgia, but nationwide.

When I started investigating this subject, I was astounded to realize just how challenging things were for these cornerstones of our health care system, and just how heroic are their efforts to continue to provide the quality of care that they do, day in, day out, for every single person who comes through their doors, regardless of their ability to pay.

Hospitals are being squeezed from every side. The population is growing and aging, requiring more care, and more expensive care to boot. The number of completely uninsured are rising -- 1.3 million Georgians don't even have Medicaid or Medicare -- and reimbursements from insurance companies and the government are dropping. Due to Georgia's budget crisis, Medicaid pays less than 90 percent of a hospital's actual costs, and in a few weeks that percentage will fall even further. At Scottish Rite alone, according to its IRS filings, at the end of 2002 the hospital expected to write off nearly 60 percent of its overdue accounts. And Scottish Rite isn't exactly in the inner city. All told, nearly 60 percent of Georgia hospitals lose money in providing patient care.

As stress levels skyrocket and the nursing shortage looms, every one of our hospitals does more, with less, without compromising the quality of care.

Georgia Hospital Association spokesperson Kevin Bloye drew a comparison that I had never really thought about before. "Hospitals don't turn patients away, and I can't think of any other industry like that. You can't walk into the grocery store and say, 'I don't have the money, but I need to eat, so I want to take these items please.' Hospitals are different, and that just goes to show you the level of commitment that they have to their community."

And for the word "hospital," substitute "people." Because that, in the end, is the reason these facilities continue to provide the level of care that they do: They are filled with committed, caring people who will go the extra mile, work the extra hours, and endure the inevitable toll on their own lives, because they are making a critical difference in the lives of others.

The second week of May was National Hospital Appreciation Week, and I bet most of us missed it. I know I sure did. Until the next day, when reality gave me a crash course in gratitude for those who work on the medical front lines every day, under the most challenging conditions.

So on behalf of all of us who have never really appreciated that before: a heartfelt thank you.

Emphasis is mine. Have a nice weekend and a safe Memorial Day.


Thursday, May 27, 2004

An email from a reader:

I am an incoming 1st year medical student at the Medical College of Georgia and am starting some introspection regarding residency options. Upon choosing to enter the medical profession, Hem/Onc has been my primary consideration as a future career path. Recently and probably very naively, I have been looking at surgery because I believe from limited experience it suits many characteristics that I find in my own personality and for the simple reason of the challenge of the work. More to the point of this email, is to ask about the balance between your profession and other aspects of your life. Also, how do you see the future landscape of surgery in the changing medical system, ie. demand, increasing mal-practice insurance, decreasing reimbursements.

First off, congratulations on your acceptance to the Finest Medical School in the Free World. When I started medical school I had the experience of working in a hospital ED for several years and would spend my vacations following physicians in various specialties around while they did their work. This gave me an informed perspective on how various specialties work in the "real world". I actually started medical school wanting to be an orthopedist but a kind surgical resident took me under their wing and got me interested in general surgery. Don't be surprised if you get into school and change your mind about what you want to do, and feel free to explore multiple career choices. That being said the competitiveness of many residency programs requires one to commit early to a path to allow for maximization of placement options. You might find this book, Iserson's Getting into a Residency: A Guide for Medical Students, Sixth Edition helpful.
As to the balance between surgery and the rest of my life, well I am fortunate that I am in practice with a group that recognizes that serious time must be made for families. I still miss more than my share of school functions and the like, and it will probably get worse as my children become older. Luckily Mrs. Parker has the patience of Job with such things, and has throughout medical school and residency.
The future of surgery is going to be one of increasing use of laparoscopy and other minimally invasive techniques. As far as the effects of reimbursement and liability premiums on the practice of surgery only time will tell. I fear that it will take more actions such as the one described below before things get better. I do not see the work that a surgeon does diminishing anytime soon, and surgeons may become busier with 60 percent of respondents to an American College of Surgeons survey between 40 and 59 years old.
The student then wrote again:

Also, just out of curiosity could you give me insight into some of the emotions you had when first entering your intern year of surgery? More specifically, I do consider many aspects of my personality and interests in line with surgery, but looking from the distance and innocent position of an incoming first year med student, I have what could be described as anxiety about the contemplation of a life as a surgeon, but this is what also seems attractive, the challenge. Is this feeling a normal part of the student or intern experience, or were you as a surgeon without anxiety about your occupation?

I was scared to death of making a mistake. The feeling of many is similar to that expressed by Dr. John Carter of ER fame. When faced with a difficult patient he yells, "Somebody get the doctor!!" to which a nurse replies: "You are the doctor." Then it hits you. As you progress through your residency the ability to deal with such matters improves and your anxiety level falls as well. The anxious feeling is natural and a good thing because it shows you are concerned about your patients and your performance. I have anxious moments from time to time even now. The important thing that you have to learn, all macho BS aside, is to not lose control. Once you do the confidence that your patient and other members of the team has for you is gone and difficult to recover.

I hope you have found this helpful. This site sponsored by the ACS: "SO, YOU WANT TO BE A SURGEON..." may also be useful. It is from a book by the same name that is no longer in print, but was a treasure trove of information for me back in the day.

Just try not to get stereotyped. (via Michelle Au).

Wednesday, May 26, 2004

In the latest Bulletin of the American College of Surgeons (PDF) The Story of Tort Reform in West Virginia describes the near-meltdown of a state's medical infrastructure that has led to one of the most progressive tort reform packages in the nation. The story is one of the power physicians hold when they "hit them where it hurts":

In the already overburdened Level I trauma center in the state capital of Charleston, the orthopaedic surgeons finally rebelled, faced with an avalanche of patients being transferred to their institution around the clock from outlying communities that found themselves without orthopaedic coverage or the courage to assume the risk of liability. The surgeons announced the decision to stop taking trauma call. Immediately thereafter, the hospital was downgraded to a Level III trauma center. The public perception based on the media coverage was that the hospital was essentially closed for all critical patients. The state capital was in an uproar as the legislature was about to convene for the 2003 session.

While this did not get much coverage nationwide, what followed most certainly did:

a large group of northern panhandle surgical specialists stopped all their elective cases. Hospitals in the area, which were already struggling under inadequate reimbursement, began to suffer mounting losses in income. The hospital association’s involvement in the lobbying effort intensified dramatically.

Coverage of that may be found here. While the ethics of such a move may be debated, there is no doubt that it was effective. It was effective because it forced the politicians and citizens of West Virginia to see the consequences of an out-of control tort system firsthand. It was no longer a theoretical problem, it was here and now. And just what did the physicians get for their efforts:

Critical portions of the tort reform bill include a $250,000 cap on noneconomic damages and a $500,000 cap on all damages for treatment of emergency conditions for patients who receive care at a designated trauma center. Joint liability has been eliminated, and each individual defendant bears liability equal to his or her percentage of fault. Collateral payments, which had not been allowed in court before, may now be presented. The “ostensible agency theory” of liability was abolished. Additionally, a committee was established to develop a patient injury compensation fund to provide for economic damages that exceed financial limits set in the bill.

Sounds like just what the doctor ordered...

Tuesday, May 25, 2004

Despite the fact I have not lived or practiced medicine in West Virginia for several years, I have held a West Virginia license but am now planning to go inactive or surrender it. Apparently I am not alone:

The $1,000 fee doctors are required to pay to support a physicians' mutual may clear up whether there is a shortage of physicians in West Virginia.

Not every doctor who holds a West Virginia medical license practices in the state. Some keep their license after they retire, while others retain them even though they have moved out of the state.
Some of these doctors may relinquish or inactivate their licenses rather than pay a $1,000 fee to help fund a physician's mutual insurance program in the state, said Evan Jenkins, a state senator and executive director of the West Virginia Medical Association. The mutual was authorized two years ago.

"A lot of doctors both because of this legislation and other factors are saying, 'Thank you, but no thanks' to having a West Virginia license," said Jenkins, D-Cabell

This assessment has been in place since last year. But since there was no defined penalty for not paying the assessment many, including myself, did not pay. The West Virginia Board of Medicine (WVBOM) went so far as to explain that the legislature merely made it a "collection service" for the fees. Well that is no longer the case:

The 2003 legislation aimed at curbing rising malpractice rates included a provision for the creation of the physician's mutual to administer insurance, eventually taking over for the state's Board of Risk and Insurance Management. Because some doctors did not pay the fee, the Legislature revisited the issue in 2004, establishing penalties of a $250 fine and suspension of license for anyone who has not paid by July 1.

A wide variety of exemptions were allowed (military service and academic physicians for example) and some new ones were allowed:

An exemption was added for doctors with inactive licenses, which state Board of Medicine Executive Director Ronald Walton said is one reason 89 doctors had inactivated their licenses this year as of May 4, compared to three in all of 2003.

"This most recent activity is a direct result of the law being passed this past legislative session," he said.

An inactivated license means a physician cannot practice medicine in the state, Walton explained. However, reactivating the license is easier than acquiring a new one if the original license has been surrendered, he said.

Still, 190 physicians surrendered their licenses in 2003, and 42 had done so this year as of May 4.

Another problem with this is that if a sufficient number of physicians surrender or go inactive, the WVBOM may experience a funding shortfall (the fee for renewal is $300 and the fee for an inactive license is $100).

One silver lining is that there may be an accurate number of physicians practicing in West Virginia now, which will prove or disprove the assertion of tort-reform advocates that the tort crisis is driving physicians out of West Virginia.

Saturday, May 22, 2004

Mr. David Giacalone takes issue with Mr. Olson's and my opinion on caps for client protection funds. I appreciate the point made by Mr. Giacalone that the client protection funds are a separate entity and that individuals are free to pursue lawsuits against lawyers that they feel have defrauded them. Mr Giacalone writes:

Typical losses covered include the theft of money from estates of dead clients; escrow funds in real property closing; settlements in personal injury actions; and money embezzled from clients in investment transactions.

So these funds serve to compensate the client for what appears to be criminal conduct on the part of their attorney. A point that Mr. Giacalone does not mention, but Mr. Olson does, is that the caps advocated by physicians and others would apply only to non-economic damages. I have seen nothing that indicates that these funds provide any compensation for "pain and suffering".
And according to the Georgia Bar website there is not even a legal right to payment.
Mr Giacalone then inquires about any analogous programs for physicians. The Florida and Virginia no-fault cerebral palsy funds. These are funds, supported by annual contributions ($5,000 to $250)by all physicians, regardless if they practice obstetrics or not. While the argument may be made that this program's primary purpose was to assist with liability insurance affordability, do not client protection programs also have an effect on liability insurance for attorneys?

Thursday, May 20, 2004

Yesterday's trauma talk went well and call has become a little less strenuous the past week. I had a short day today because Mrs. Parker is in a wedding this weekend and had to leave today for the bridesmaids luncheon. How is all that wedding stuff going? Well just look here.
My two cases were an exercise in extremes:
The first was a laparoscopic cholecystectomy on a four year old, yes a four year old. I had done one on a six year old a year ago. Usually these kids have hemolytic diseases (most often sickle cell anemia here in the south) but this child has sickle cell trait and had been treated for hyperbilirubinemia as a newborn. Used five millimeter ports with the camera port lower than usual. Fun case.
The second was a IVC filter on a 560 pound man. The usual OR table I use for this had a weight limit of 350 pounds. The table rated for 750 pounds would not allow the c-arm to see what I needed. We ended up using the usual table and the patient's bed to accomplish the task.
Well my precious offspring are up to something destructive so I better go...

Monday, May 17, 2004

From Overlawyered:

Most of organized lawyerdom, as we know, strongly opposes any notion of capping damages recoverable by victims, even as applied to "non-economic" damages claimed for intangible harms such as pain and suffering or emotional distress. It turns out, however, that the bar enthusiastically supports the capping in nearly every state of one particular form of compensation, namely, the compensation of clients who are embezzled from or otherwise defrauded by their lawyers. In Pennsylvania, for example, the official Pennsylvania Lawyer Fund for Client Security (more) caps damages payable to defrauded clients at $75,000, although the loss actually sustained by the victimized client often runs far higher than that. Columnist Don Spatz of the Reading, Pa. Eagle notices the irony: "Even if you can prove your lawyer stole $200,000 from you, you're out of luck. There's a cap. ... I haven't heard lawyers worry about caps taking away those victims' rights."

As usual Mr. Olsen hits it right on the head:

In a number of states, it should be noted, lawyers impose an effective cap of zero on this particular kind of claim, by the simple method of not having established any collective client protection scheme at all. And there is a certain very plausible logic to that position: why after all should rank and file attorneys be asked to clean up the messes left by their errant brethren? Is a lawyer his brother's keeper? It's just that this argument would sit better were the leaders of the bar not constantly denouncing the medical profession for its alleged failure to police itself.
From The Wall Street Journal: Doctors' New Tool To Fight Lawsuits: Saying 'I'm Sorry'

When a medical mishap turned Linda Kenney's routine ankle surgery into a chilling brush with death, the family quickly paid a visit to a lawyer's office.

A jury, the family suspected, would likely show little mercy to the anesthesiologist, Frederick van Pelt, who inadvertently injected a painkilling drug in the wrong place, causing Ms. Kenney's heart to stop. To restart it, doctors at the Brigham and Women's Hospital sliced into her chest and cracked open her rib cage. Ms. Kenney's husband, Kevin, "wanted to kill the anesthesiologist, flatten him," says the 41-year-old mother of three.

But then, Dr. van Pelt broke with convention. Against the hospital's advice, he wrote Ms. Kenney a personal letter saying he was "deeply saddened" by her suffering. Later, over coffee at a suburban diner, he apologized for the terrible accident.

"I found out he was a real person," Ms. Kenney says. "He made an effort to seek me out and say he was sorry I suffered." Moved by the doctor's contrition, Ms. Kenney dropped her plans to sue.

Insurers and hospital lawyers have long discouraged doctors from apologizing to harmed patients for fear that such apologies might fuel lawsuits. The rule has always been "not to talk about the events to anybody," says Dr. van Pelt. "Even a passing comment can be subpoenaed."

But with malpractice premiums soaring and a national patients' rights movement pushing for full disclosure of medical errors, the industry is rethinking the traditional approach known as "defend and deny." Stories such as Ms. Kenney's are persuading a growing number of hospitals, doctors and insurers that apologies may end up saving some of the huge sums paid out to settle disputes over medical care.

With only a few states with laws protecting physician apologies from being admissible in court, such a declaration carries risks. Your results may vary, as they say.

On the other hand:

Yet some plaintiff lawyers say an apology can disarm a malpractice case. Boston attorney Andrew Meyer, who represents victims of medical malpractice, says his job is much more difficult when doctors fall on the sword. "The hardest case for me to bring is the case where the defense has admitted error," and apologized to the injured patient, he says. "If you have no conflict, you have no story, no debate. And it doesn't play well."

Probably because you won't have an arrogant SOB sitting in the witness stand during trial, denying that anything happened. A situation that these people love.

It is interesting to note that the cases mentioned in the article were those that a liability carrier would make a big push to settle rather than go to trial. Another thing that is clear is that an apology didn't let the physicians off the hook, there was still some compensation involved, just a great deal less than could have been awarded at trial.

Sunday, May 16, 2004

Nurse X: "Doctor Parker, we need a central line on Mr. Jones"
Me: "Why does Mr. Jones need a central line?"
Nurse X: "He needs blood and has meds going through his peripheral sites"
Me: "Why can't you piggyback the blood on?"
Nurse X: "We just can't"
Me: "Why?"
Nurse X: "The medications may be incompatible with blood"
Me : "Say again?"
Nurse X: "I said the medications may be incompatible with blood"
Me: "What is that medication mixing with when it leaves the IV catheter?"
Nurse X "Well, I've never thought about it that way"

Nurse X and I chewed over this while I was placing Mr.Jones' line. We cane up with two reasons, one of which I eliminated later:

Reaction problems: If you are giving a medication and blood through the same line, and the patient has a reaction, was it caused by the blood or the medication? This is probably not the reason since blood and meds can be given through different ports of a central line at the same time.

It's not the blood, but what it's mixed with: The medications may be incompatible with the citrate used in the preparation of the packed cells.

Can anyone give a logical explanation as to why you can't piggyback medications with blood? I don't ask for chapter and verse citations, but something other than the dogma of"that's just the way it has always been done" would be most appreciated.

Friday, May 14, 2004

The patient I mentioned earlier:
Late 20's man shot twice, once in right shoulder with bullet underneath the skin above his clavicle. The other one entered his back along the right psoas muscle and exited just below the left costal margin in the midclavicular line. Hypotensive but A&O. To the OR....

Colon injury at hepatic flexure: If tissue destruction is slight, primary repair is the treatment of choice. He had quite a bit of tissue destruction so I resected the area with intent to re-anastamose it. But as the Ginsu man says, "Wait...there's more!!"

Duodenal injury: Several options exist for repair. Primary repair with drainage, repair with duodenostomy tube, or duodenal exclusion. This involves oversewing the pylorus with an absorbable suture and constructing a gastrojenjunostomy. The rationale is that the suture will dissolve after the repair has healed. If severe a trauma Whipple may be required. I repaired the injury and placed a sump drain.

Vena cava injury: Since this was a zone 2 retroperitoneal penetrating injury, inspection of the hematoma was required. As a surgeon you hate any kind of bleeding, especially the kind you can hear. While distal control is achievable, proximal control this situation would be difficult, to say the least. Using spongesticks control was gained and the vein was simply repaired. Of course the patient was cold and coagulopathic so I sewed on a bag and went to the unit...

Later that night, after he was resuscitated, he began to bleed again. Re explored and found some mesenteric bleeders and a portal vein injury. What likely happened was that the portal vein had suffered some blast effect and only gave way when his pressure rose. New bag and back to the unit...

POD 3: Returned for re-exploration. No further bleeding. Revised the duodenotomy, placed a duodenostomy tube, a gastrostomy tube, a jejunostomy tube, an additional sump drain, and brought out the distal colon as a mucus fistula and created an ileostomy. Another new bag

POD 6: Back for attempted closure, tracheostomy, and removal of the bullet. Was able to get about a third of the way closed. Patient beginning to experience the "loss of domain" associated with an open abdomen.

Trauma is soooo much fun!!!


Tuesday, May 11, 2004

Sorry about the lack of posts lately. I was on call last Thursday and it was yet another gunfight at the OK corral. Two GSW's and a stabbing. I had to bring one of the GSW's back for further bleeding (I'll post more on that later). I was also an call both Saturday and Sunday as one of our call group became ill and I had to fill in for him. On top of all this I have to give a trauma talk next week. This has left me with little time for blogging or computer gaming.
I also agree with Dr. Smith's opinion on the new Blogger setup. Makes TypePad more attractive all the time.....

Wednesday, May 05, 2004

One of the great things about trauma surgery is that you can read about your night's adventures the next day in the paper....

A 51-year-old man who was shot by police Monday night after firing at officers during a three-hour standoff outside his XXX Avenue home died of his wounds early Tuesday......(the patient) pronounced dead at 3:16 a.m. at Big Hospital of a gunshot wound to the abdomen, authorities said. Police Chief Officer Friendly said (the patient)...... was shot once after he emerged from his home with a gun in his hand pointed at officers.

Once officers arrived, they encountered (the patient) dressed in a robe, walking down the street as he opened fire on police.

A crisis negotiation team was called in and several attempts were made to coax (the patient) from the house. He had re-entered the house after firing the first shots.

About 9:30 p.m. (the patient), then nude, left his home again, walked toward the driveway and pointed a gun in the direction of officers. At that point, he was shot once by.... a SWAT team member.

He arrived with an entry wound at his mid-axillary line at the costal margin on the right... and a large exit wound at his left flank with omentum and colon protruding. His injuries:
Multiple wounds along length of transverse colon with spillage.....colectomy (transverse, distal ascending and proximal descending)
Small bowel injury at ligament of Trietz....debrided and stapled off the ends.
Tangential wound to posteror gastric wall....primary repair
Shattered left kidney...nephrectomy
Shattered inferior pole of spleen...splenectomy
Devacularized distal pancreas....distal pancreatiectomy
I also placed packs within the exit wound site to try to control the bleeding from rib fractures. Bag was sewn on to avoid compartment syndrome. Totals: 21 PRBC's, 6 FFP, and 10 units platelets. The plan was to get him to the ICU for the usual resuscitation and warming with a return in 24-36 hours for pack removal and try to restore continuity to his GI tract. But as you can see from the above he didn't make it.

Somedays you get the bear, somedays the bear gets you...

Monday, May 03, 2004

Hospital CEOs' pay a heated issue

Seventeen thousand babies a year.

The annual baby boom at Northside Hospital - more deliveries, it says, than any other community hospital in the United States - helps sustain the Sandy Springs facility's reputation and revenue.

Its chief executive's pay reflects that success. Compensation for Northside CEO Sidney Kirschner, with a salary of $965,680 plus a one-time bonus of $1 million, topped that of other executives leading Georgia nonprofit health systems and hospitals in their 2002 fiscal years.

Kirschner's pay is high on lists of Georgia hospital salaries compiled by groups opposing major revisions in Georgia's medical malpractice system. Tort reform was fiercely contested in the recent General Assembly session but failed to pass.

Bill Clark of the Georgia Trial Lawyers Association, which fought a proposed $250,000 cap on "pain and suffering" damage awards in malpractice cases, says the size of executive pay guts the argument that hospitals teeter on the financial brink.

"These organizations scream poverty, when at the same time spending exorbitant amounts of money on CEOs' salaries, benefits and perks," Clark says.

Pu-leez, talk about a straw man. What's next, an argument that physicians are overpaid and they don't deserve relief? I, like many physicians I know, complain about how much hospital administrators are paid all the time. But I can see the rationale behind the "hospitals are businesses and their CEO's need to be paid like private sector CEO's". Looking at the chart there is not a solid connection between CEO pay and hospital revenue.
The fact is that most hospitals in Georgia are self-insured, since hospital underwriting is so expensive. Even those who can get a policy pay dearly for it:

DeKalb Regional Healthcare System, for example, says its malpractice premiums increased $3.1 million to $8.8 million in 2003. The system's net income was about $1 million in fiscal 2002.

Given that according to MAG Mutual their average plaintiff award in 2002 was $4.65 million and the average payout was $457,000, you can see that one case can put a serious dent in any net income that a hospital may generate.

Sunday, May 02, 2004

Good review from this month's Bulletin of the American College of Surgeons. The review is well written and provides a summary of EMTALA's origins and the new regulations. Most of the article deals with the new policy concerning call coverage for hospitals. Essentially it allows hospitals to set up their call rosters "in a manner that best meets the needs of the hospital's patients in accordance with the capability of the hospital, including the availability of on-call physicians.”. There is now approval for such things as covering more than one hospital and performing elective surgery while on call, things that went on before the regulations were changed.
The regulations deal with the "I'm not credentialed for that!!" dodge:

Many physicians limit their scope of practice to well-defined subspecialty areas, even though they are often credentialed by their hospitals to perform all surgery for the broader specialty for which they are board-certified.” For example, a neurosurgeon with limited privileges for spine surgery would argue that he or she is not required to take call for head trauma. Surgeons should be aware that CMS addresses this issue in the current regulations, and hospitals may soon begin to move toward defining core privileges for a number of specialties. CMS states that “a physician who is in a narrow specialty may, in fact, be medically competent in his or her general specialty, and in particular may be able to promptly contribute to the individual's care by bringing to bear skills and expertise that are not available to the emergency physician or other qualified medical personnel at the hospital

But several problems remain....

While the federal government has come a long way in addressing the concerns of the medical community regarding the scope of EMTALA, a number of issues remain that will continue to affect access to emergency surgical care. These issues include: managed care reimbursement policies and emergency room overcrowding; proliferation of single-specialty hospitals; lack of liability protections for EMTALA-related services; and growing burdens on trauma centers and community hospitals.

One such pressure revolves around patients’ inability to receive timely access to specialty care in the nonhospital setting. More often than not, managed care plan enrollees, some of whom are knowledgeable about EMTALA requirements, may use the emergency room when they cannot get an appointment with their regular specialist or primary care physician..... This kind of nonemergent saturation of emergency room departments across the country, particularly in urban areas, is resulting in numerous injured patients being unnecessarily diverted—causing critical delays for individuals requiring acute care.

I can imagine where a savvy managed care patient could use such a situation to do an "end run" around the requirements of their managed care plan. But that's not the worst of it IMHO:

Furthermore, while many physicians are heralding the recent changes in EMTALA’s on-call requirements, others, particularly in the trauma community, are worried that these changes will further exacerbate the financial difficulties facing trauma centers and community hospitals. Under EMTALA, hospitals are now only required to maintain an on-call list “in a manner that best meets the needs of the hospital’s patients in accordance with the capability of the hospital, including the availability of on-call physicians." Many trauma professionals believe that this change in the regulation will provide hospitals, particularly for-profit entities, with the ability to shield themselves from caring for severely injured patients by limiting on-call schedules. For example, some hospitals may only provide on-call coverage until 9:00 pm every night—leaving the local trauma center as the provider of last resort.

This is already happening at some smaller local hospitals, some not-for-profit, and it's not limited only to trauma. This was a major concern brought up during the Trauma and Critical Care meeting in Las Vegas. Unfortunately this is one of those issues that is likely to get worse before it gets better.

Read the whole thing.
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When I try to get to the FAQ page on the WCC site I repeatedly get a 404 message.
Can anyone help?

Saturday, May 01, 2004

Stent recommended to prevent strokes

A panel of scientific experts cautiously approved a new stent Wednesday that is intended to prevent strokes by opening a channel in either of the two arteries that feed the brain.

Stents, small mesh-like tubes, have been used for a decade to prop open plaque-plugged coronary arteries. The devices are put in place by a catheter threaded through the groin and guided to the plugged site.

Doctors who have participated in clinical trials of the device say placing the tiny props in one of the two carotid arteries is less invasive than a 50-year-old surgical procedure, carotid endarterectomy, in which the artery is opened and plaque is scraped away from interior walls. About 200,000 Americans a year undergo the surgery.

Full approval is expected by July. The stent and protection devices are manufactured by Cordis. The company is putting physicians through a pretty rigorous program before allowing them to place the device. This consists of training on a simulator to assure compentency in carotid angiography, as well as managment of the device itself. Once that goal has been reached the first five stents placed will have to be proctored. If they do well only then will the device be released to the physician to place as they see fit.
The company not only does this for patient safety, but because of the liability they can face if such a device is misused. I will be interested in following this as the stent becomes more widely available. I fear that the results of the much-lauded SAPPHIRE trial will be "diluted" when more carotid stenting is performed.
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