Sunday, June 28, 2009


I'll be on a medical mission for the next two weeks with doubtful internet access for posting.

Until then, hassle Happy (see sidebar).

Treating Me In Dementia

I had a long-time patient tell me last week that she had a solution for her own future dementia.

She would rig a bomb and wrap it as a gift to herself. If she ever developed dementia, she'd forget what was in the box and open it.

A nurse told me her advance directive includes a provision that if she cannot remember to ask for her medicines, she's not to receive them.

I'd add the exception that the care provider should give me morphine, antiemetics, haloperidol and lorazepam as needed.

Any other ideas?

Tuesday, June 23, 2009

Does Canada Really Make Patients Wait?

In the debate about a Government-run National Health Plan, impressions of the Canadian system loom over any proposal. The influence can be subtle, educated, or not. Often it degenerates into the exalted format of childhood arguments:"Does!" "Does not!" "Does too!" etc...

Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.

Highlights of the report include an average 8.5 week wait from referral to seeing a specialist, and another 8.7 weeks to receive the treatment recommended by that consultant. One of the shortest waits was medical oncology (think chemotherapy) which was 4.6 weeks from referral to treatment. Overall the wait times nearly doubled compared to 1993 (referral to treatment went from 9.3 weeks to 17.2 weeks in 2008).

One can well argue whether these waiting times are medically significant or not, whether this person or that person might have "had an untoward outcome" as a result.

My point instead is that Canada's medical system is not the health care nirvana that some claim. Canada has rationing by an ever lengthening queue. 

No national health care system can afford to pay for everything, for everyone, always.  All the handwaving about 'efficiencies' and EMRs will not conjure enough cash to prevent rationing, whether open or covert

Tuesday, June 16, 2009

When The Consultant Is Non-Compliant

Pay for Performance (P4P) and the Patient Centered Medical Home are two of the schemes being touted to save the nation from nefarious, inept and greedy doctors. Chief among arguments for these ideas are that more structured routine medical care will "increase quality" and "reduce health care costs". In essence, reward docs to do what 'someone' wants them to do (and imply future penalties if they don't).

An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.

I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.

The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!

Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?

Friday, June 12, 2009

Why Should I Care If Physicians Lose Autonomy?

How does the loss of the conscience clause threaten physician autonomy? How would that affect me?

The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.

The someone will be a government medicrat.

If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.

If the doctor is forbidden to provide a service, the patient cannot receive it.

Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.

Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.

No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?

Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.

Otherwise, expect your bladder difficulties to be treated by Vogon poetry.

Monday, June 8, 2009

Saving Medicare and Social Security

We need to encourage (=pay) all the Boomers to try this.