I wonder if I will be the last independent practicing ENT doctor in my community. Over the past years I have seen a continuous onslaught of changes all of which are targeted to benefit large corporations but are a burden to my little three man group. I know these changes aren't only impacting me but also any small group of doctors trying to negotiate the web of insanity.
Will we survive the next ten or twenty years?
I hope so because I am certain that the one advantage a small group has is the ability to target our care to the individual patient. When we see a need to slow down and go down a different path we can do it. If a new treatment or algorithm comes out we can make the change right away. No waiting for the corporate office for review and approval. If a patient has a complaint or a compliment it goes right to the top. No hierarchy of people between the patient and the doctor.
So why am I so concerned?
Crippling new regulations are being passed by our state and federal governments every year. For me to really comply I would need a full time attorney and a medical consultant. Obviously, us small guys can't afford that. For example, Medicare decides they want us to switch to sending in your prescriptions electronically. No problem, we spend the money, buy the software, retrain our staff and we're doing the job. But that isn't the end. They want me to prove to them I am doing this. So back in 2009 they ask me to submit a letter to them on every patient I see Medicare or not with a special code. I do this. Then in 2010 they decide to change the code. Now in 2011 I think they are changing again. By the way, do they tell me this? No, they wait until November to send me a letter that I might be doing things wrong but they don't even tell me what it is.
Hmmm, how does the little guy survive?
How about a little bit of ridiculous? The State of California has a law that I need to return a call to you within thirty minutes. Sounds reasonable doesn't it? How about if you're calling about your prescription refill while I am in the emergency room saving someone's life. Which should the priority be? Hmmm.
Even better, they have a law on the books that I have to see patients within fifteen minutes of their appointment time. What if the patient is late, am I still in trouble? Hmmm, how about a penalty if our legislators don't pass a budget within fifteen minutes of deadline? Sounds reasonable to me.
So why is this worse for my little group than the big guys? The big guys can hire people to make sure the i's are dotted and the t's crossed. Meanwhile, they watch us little guys suffer.
What will happen when the last of us closes shop? I guess independent businessmen have been suffering this fate for decades. Maybe a few of us will figure out ways to survive. Maybe we can find a way to team up, but you can imagine trying to have a bunch of independent people agree can be a challenge. Meanwhile, the geniuses in Washington, D.C. and Sacramento are going to paint themselves in to a corner. Because without us little guys to push around the big guys are going to fight hard for their interests. And you can guess who will win that battle. Just look at how the banks have controlled our economy. Well guess what? Health care is 16% of our gross national product. That's a mighty big tail swinging the dog.
What can we do?
I'm open to ideas, tell me!
Monday, November 7, 2011
Tuesday, June 21, 2011
Drugs Alcohol our Kids and Their Brains-Some Answers
I have been under the impression for a long time that our kids issues relate to how we raise them and counsel them and whether our family life is stable and supportive. But, now I have a completely different view. I just returned from a trip to Virginia where I attended some amazing seminars that finally gave me answers as to what is going on in the heads of our kids. I believe that what I learned needs to be shared so that we all understand our kids better and can do a better job helping them survive into adulthood.
There are two gentlemen from Duke University, Aron White and Jeff Georgi, who have studied adolescent behavior and have shed a lot of light on what is going on in our kids heads and why it seems behavior has been changing over the past several decades. If your like me you've been scratching your head when you look at today's young adults. They look more mature than we ever did. Thirteen year old girls sometimes look like mature woman. On the other hand even at age eighteen or older they seem lost regarding their future. They have a hard time committing to work or school and me and my friends constantly complain that today's kids seem immature compared to our generation.
Well guess what? They are! And, there is science to prove it and this science makes everything make sense. My goal is to give you a synopsis of what these two men from Duke taught me last week and using some of my own inferences I want to help us all to understand our kids and how we can help them make good decisions.
First, we need some definitions. Puberty is the physical changes we experience that turns our bodies from child like into an adult with adult sex characteristics that enable us to reproduce. These changes include our appearance with hair growth, voice changes, breast development, menstreuation, etc.
Adolescence is the changes our mind makes that moves us from childhood and dependence on our parents to adulthood with independence and the ability to raise our own families. Adolescence is characterized by anxiety, loss of interest in family, a need to develop a pack of friends, desire to experiment, boredom, lack of insight of the future, etc.. Particularly interesting is that during adolescence our ability to learn and remember is the best we will have in our entire lives and simultaneously our brain is firing off signals that cause us to be impatient and anxious.
Is it just me or do we all remember our parents complaining that our generation seemed to be unfocused, lazy, reckless etc.? Much to my dismay I recall having very similar conversations with my friends about the current generation coming of age. So, is this because as we get older we get more critical or is something really going on here? Surprisingly, something is actually going on. Over the past 60 or more years the age of puberty is getting younger and younger. Sixty years ago onset was around twelve years old in girls and now it is at age nine. Therefore, our observation that these twelve year old girls look like young woman and nothing like the twelve year olds when we grew up is actually correct. Ironically, while puberty is hitting at a younger age adolescence has been turning on later. The result is that sixty years ago adolescence kicked in around age twelve and ended around eighteen now it starts around age fourteen and doesn't completely end until close to age twenty-five. I'm not making this stuff up there are actually publications on this.
So, think about this, our kids look more mature at a younger age but their brains are less mature until an older age. Not only is their brain less mature but it is taking dramatically longer for them to emerge from this. The result is that every new generation is taking longer to grow up and act like the adults they look like.
Now I'm going to really scare you. A whole bunch of studies have been performed on adolescents regarding drugs and alcohol and the impact on their behavior and development. First, remember their brains are firing off the anxiety neurons so much that they feel anxious and at the same time very bored. As an answer they use alcohol or drugs which calms down those hyperactive neurons and this makes them feel really good. The effect is way more powerful than it is on us adults. At the same time the circuits in their brain are trained to learn. So their brain hardwires in that drugs or alcohol will make them feel really good. At the same time they are imprinting that this is an activity they can share with friends and creates very positive memories.
Unfortunately, the frontal lobe of the brain, the part that lets us look into the future and anticipate the consequences of our actions is still incompletely developed. Therefore, they don't "see" that they could hurt themselves by their actions. We all remember the feeling of invincibility we had as teenagers. This is actually a biological result of incomplete development of the brain.
On the other hand, teens have a very well developed cerebellum which controls balance and coordination. Therefore they can consume far more alcohol or drugs than an adult brain and still walk and look normal. On top of this their brain does not get sedated from alcohol but rather stimulated. So unlike us parents who have a couple glasses of wine and want to go to bed our teenagers are ready to hit the town.
Some of us wonder if maybe we could help our kids by teaching them to use alcohol responsibly. Maybe they would learn moderation and appropriate behavior. We have been told for years that the Europeans don't have alcohol issues in their youth and there isn't an enforced drinking age there. Sorry, the research shows once again that our perceptions are wrong. The European teenagers have a much higher rate of dangerous drinking than Americans with double the rate of drinking to get drunk. Studies also show that teens who are introduced to "responsible" drinking in the home have a much higher likelihood of getting drunk as well.
The reason for this again points back to how their brains are developing. They have an enhanced response to alcohol with fewer side effects and a poor ability to foresee consequences. So, now we ask, What should we do?
We asked the lecturers this very same question. They were very clear. First of all, these guys aren't Puritans. They understand that alcohol and recreational drug use can be done responsibly. But, it can't be done responsibly until after someone has begun to emerge from adolescence around age 21. Therefore, they recommend that we do everything in our power to keep our kids from using drugs and alcohol. They even recommended routine drug screening or hair samples since it can show drug use 90 days old and the test can't be beat. They didn't say what age to start but I suspect probably in middle school.
This seminar was very enlightening to me because it basically killed all of my assumptions. I now know that my kids are maturing slowly and are very susceptible to the effects of drugs and alcohol and I should be vigilant in trying to keep them from using them. I will probably consider routine drug testing. I figure that if a test is positive it gives us a chance to talk about what's going on. And, preferably, if negative it gives my kids the excuse to say "no" when peer pressured.
What do you think? Have I presented anything here that might change the way you raise your kids?
There are two gentlemen from Duke University, Aron White and Jeff Georgi, who have studied adolescent behavior and have shed a lot of light on what is going on in our kids heads and why it seems behavior has been changing over the past several decades. If your like me you've been scratching your head when you look at today's young adults. They look more mature than we ever did. Thirteen year old girls sometimes look like mature woman. On the other hand even at age eighteen or older they seem lost regarding their future. They have a hard time committing to work or school and me and my friends constantly complain that today's kids seem immature compared to our generation.
Well guess what? They are! And, there is science to prove it and this science makes everything make sense. My goal is to give you a synopsis of what these two men from Duke taught me last week and using some of my own inferences I want to help us all to understand our kids and how we can help them make good decisions.
First, we need some definitions. Puberty is the physical changes we experience that turns our bodies from child like into an adult with adult sex characteristics that enable us to reproduce. These changes include our appearance with hair growth, voice changes, breast development, menstreuation, etc.
Adolescence is the changes our mind makes that moves us from childhood and dependence on our parents to adulthood with independence and the ability to raise our own families. Adolescence is characterized by anxiety, loss of interest in family, a need to develop a pack of friends, desire to experiment, boredom, lack of insight of the future, etc.. Particularly interesting is that during adolescence our ability to learn and remember is the best we will have in our entire lives and simultaneously our brain is firing off signals that cause us to be impatient and anxious.
Is it just me or do we all remember our parents complaining that our generation seemed to be unfocused, lazy, reckless etc.? Much to my dismay I recall having very similar conversations with my friends about the current generation coming of age. So, is this because as we get older we get more critical or is something really going on here? Surprisingly, something is actually going on. Over the past 60 or more years the age of puberty is getting younger and younger. Sixty years ago onset was around twelve years old in girls and now it is at age nine. Therefore, our observation that these twelve year old girls look like young woman and nothing like the twelve year olds when we grew up is actually correct. Ironically, while puberty is hitting at a younger age adolescence has been turning on later. The result is that sixty years ago adolescence kicked in around age twelve and ended around eighteen now it starts around age fourteen and doesn't completely end until close to age twenty-five. I'm not making this stuff up there are actually publications on this.
So, think about this, our kids look more mature at a younger age but their brains are less mature until an older age. Not only is their brain less mature but it is taking dramatically longer for them to emerge from this. The result is that every new generation is taking longer to grow up and act like the adults they look like.
Now I'm going to really scare you. A whole bunch of studies have been performed on adolescents regarding drugs and alcohol and the impact on their behavior and development. First, remember their brains are firing off the anxiety neurons so much that they feel anxious and at the same time very bored. As an answer they use alcohol or drugs which calms down those hyperactive neurons and this makes them feel really good. The effect is way more powerful than it is on us adults. At the same time the circuits in their brain are trained to learn. So their brain hardwires in that drugs or alcohol will make them feel really good. At the same time they are imprinting that this is an activity they can share with friends and creates very positive memories.
Unfortunately, the frontal lobe of the brain, the part that lets us look into the future and anticipate the consequences of our actions is still incompletely developed. Therefore, they don't "see" that they could hurt themselves by their actions. We all remember the feeling of invincibility we had as teenagers. This is actually a biological result of incomplete development of the brain.
On the other hand, teens have a very well developed cerebellum which controls balance and coordination. Therefore they can consume far more alcohol or drugs than an adult brain and still walk and look normal. On top of this their brain does not get sedated from alcohol but rather stimulated. So unlike us parents who have a couple glasses of wine and want to go to bed our teenagers are ready to hit the town.
Some of us wonder if maybe we could help our kids by teaching them to use alcohol responsibly. Maybe they would learn moderation and appropriate behavior. We have been told for years that the Europeans don't have alcohol issues in their youth and there isn't an enforced drinking age there. Sorry, the research shows once again that our perceptions are wrong. The European teenagers have a much higher rate of dangerous drinking than Americans with double the rate of drinking to get drunk. Studies also show that teens who are introduced to "responsible" drinking in the home have a much higher likelihood of getting drunk as well.
The reason for this again points back to how their brains are developing. They have an enhanced response to alcohol with fewer side effects and a poor ability to foresee consequences. So, now we ask, What should we do?
We asked the lecturers this very same question. They were very clear. First of all, these guys aren't Puritans. They understand that alcohol and recreational drug use can be done responsibly. But, it can't be done responsibly until after someone has begun to emerge from adolescence around age 21. Therefore, they recommend that we do everything in our power to keep our kids from using drugs and alcohol. They even recommended routine drug screening or hair samples since it can show drug use 90 days old and the test can't be beat. They didn't say what age to start but I suspect probably in middle school.
This seminar was very enlightening to me because it basically killed all of my assumptions. I now know that my kids are maturing slowly and are very susceptible to the effects of drugs and alcohol and I should be vigilant in trying to keep them from using them. I will probably consider routine drug testing. I figure that if a test is positive it gives us a chance to talk about what's going on. And, preferably, if negative it gives my kids the excuse to say "no" when peer pressured.
What do you think? Have I presented anything here that might change the way you raise your kids?
Friday, June 3, 2011
Privatize Medicare? Why give up a cruddy system for certain disaster?
Everyone has heard the screaming on the Hill about Medicare. Should we change the system and if we do how should it be done? Paul Ryan made a risky and probably foolish move when he suggested phasing Medicare into privatized fee for service insurance. Everybody with a pulse is aware of the absurd salaries and bonuses paid to executives of insurance companies for successfully avoiding paying for care. So, obiviously, if we privatize Medicare we are throwing these guys a huge multitrillion dollar bone.
I suspect that unless Mr. Ryan has a special kick back set up he was suggesting this because he recognizes a truth we all wish to ignore. Private industry is not afraid to make decisions that government leaders lack the back bone to achieve. For example, it is well known that the final six months of life tally up about one half of the entire money spent on a lifetime of health care. No one in government leadership is willing to discuss this issue. I suspect that if Medicare was privatized the insurance industry would figure out a way to deal with this. The profit potential of reducing these costs is just too staggering.
On the other hand, if Medicare is privatized there probably wouldn't be any sympathy for the dying patients who desire care. By the way, I find it very curious that a Republican leader came up with a strategy of dealing with our elderly that would most likely result in a real death panel. For those of you who think that I am reaching a bit far I can tell you that only private insurance has subjected me to panels to evaluate whether a surgical procedure I would like to perform is appropriate. Medicare and Medicaid do no such thing. Instead they try to discourage procedures they don't like by reducing payments until the reimbursement is too unpalatable to consider performing.
I suspect if we privatize Medicare the incentive to make a profit will be so strong that patient care will be delayed as long as possible. Once the insurance companies have squeezed every last drop of profit they will abandon the model and beg the government to take over. By then we will have delayed so much care that just like failing to perform routine home maintenance we will be stuck with enormous expenses. So I do suspect certain disaster if we follow that route.
Despite this, I would like to thank Mr. Ryan for his willingness to at least discuss the Medicare disaster that is looming. I suspect that if we just raised the age when full benefits kick in and phase in an increase in copays and deductibles we can delay the disaster.
An even better idea is to reform the fee for service system. We need to put more responsibility with the consumer. I mentioned in a previous blog that physician compensation has not kept up with inflation. I also understand that Medicare cannot afford to pay physicians appropriately. But, the free market can. Currently, no matter what I bill a patient I am restricted to how much money I can be paid. Because of this, each year physicians are face with either leaving the Medicare program or in order to maintain income they need to perform a larger volume of services at ever decreasing payments. The upside is consumers get more services performed the downside is that for every dollar the physician generates in an additional procedure there may be associated expenses for facility fees, lab testing, etc. And, there will always be some doctors who bend the rules of indications for procedures and do things only to generate revenue. Those dogs make the rest of us look bad. Most of us just shorten our visit times and work longer hours to keep the revenue from sinking.
Perhaps we should allow doctors to charge what they feel the market can bear. Medicare doesn't have to increase rates they just need to allow the physician to pass those costs on to the consumer. They should require us to publish what our fees are so the consumer can compare. The free market will result in people reducing their usage of services if the cost is too high. They may travel to areas where cost of care is lower. Expensive hospitals would have to prove to the consumer that they are better. We could do away with the crazy red tape that Medicare uses to show quality of care. The consumer themselves would want to know who is the best for the money.
All this without a highly paid executive trying to transfer your money into his pocket. What do you think?
I suspect that unless Mr. Ryan has a special kick back set up he was suggesting this because he recognizes a truth we all wish to ignore. Private industry is not afraid to make decisions that government leaders lack the back bone to achieve. For example, it is well known that the final six months of life tally up about one half of the entire money spent on a lifetime of health care. No one in government leadership is willing to discuss this issue. I suspect that if Medicare was privatized the insurance industry would figure out a way to deal with this. The profit potential of reducing these costs is just too staggering.
On the other hand, if Medicare is privatized there probably wouldn't be any sympathy for the dying patients who desire care. By the way, I find it very curious that a Republican leader came up with a strategy of dealing with our elderly that would most likely result in a real death panel. For those of you who think that I am reaching a bit far I can tell you that only private insurance has subjected me to panels to evaluate whether a surgical procedure I would like to perform is appropriate. Medicare and Medicaid do no such thing. Instead they try to discourage procedures they don't like by reducing payments until the reimbursement is too unpalatable to consider performing.
I suspect if we privatize Medicare the incentive to make a profit will be so strong that patient care will be delayed as long as possible. Once the insurance companies have squeezed every last drop of profit they will abandon the model and beg the government to take over. By then we will have delayed so much care that just like failing to perform routine home maintenance we will be stuck with enormous expenses. So I do suspect certain disaster if we follow that route.
Despite this, I would like to thank Mr. Ryan for his willingness to at least discuss the Medicare disaster that is looming. I suspect that if we just raised the age when full benefits kick in and phase in an increase in copays and deductibles we can delay the disaster.
An even better idea is to reform the fee for service system. We need to put more responsibility with the consumer. I mentioned in a previous blog that physician compensation has not kept up with inflation. I also understand that Medicare cannot afford to pay physicians appropriately. But, the free market can. Currently, no matter what I bill a patient I am restricted to how much money I can be paid. Because of this, each year physicians are face with either leaving the Medicare program or in order to maintain income they need to perform a larger volume of services at ever decreasing payments. The upside is consumers get more services performed the downside is that for every dollar the physician generates in an additional procedure there may be associated expenses for facility fees, lab testing, etc. And, there will always be some doctors who bend the rules of indications for procedures and do things only to generate revenue. Those dogs make the rest of us look bad. Most of us just shorten our visit times and work longer hours to keep the revenue from sinking.
Perhaps we should allow doctors to charge what they feel the market can bear. Medicare doesn't have to increase rates they just need to allow the physician to pass those costs on to the consumer. They should require us to publish what our fees are so the consumer can compare. The free market will result in people reducing their usage of services if the cost is too high. They may travel to areas where cost of care is lower. Expensive hospitals would have to prove to the consumer that they are better. We could do away with the crazy red tape that Medicare uses to show quality of care. The consumer themselves would want to know who is the best for the money.
All this without a highly paid executive trying to transfer your money into his pocket. What do you think?
Thursday, May 26, 2011
Virestorm-Chapter 2 and 3
Chapter 2
Lahore, Pakistan Farmer’s Market
Ten year old Ahmed runs through the market with his younger brother Mastouf close behind. Ahmed is laughing as he rounds the corner nearly sliding on the banana peels on the ground. He skids to a halt and Mastouf runs into him right in front of the bird cages. In front of the boys a cacophony of chirps and shouts break out among the chickens. The boys carefully look through the cages, like diamond merchants scrutinizing a collection of rare gems. The chickens are of various color combinations, some deep red, others white. Most of the birds look malnourished and weak. One is barely moving. Mastouf puts his small hand between the wires of the cage and gives the bird a poke. The bird barely moves and he pokes again. This time the bird breaks out in a riot of chirps and hisses and Ahmed yells at his younger brother, “Get your hand out of there! Are you crazy, that one looks sick.” Mastouf pulls his hand back out quickly and looks down at his feet. He is embarrassed that he disappointed his big brother. Ahmed can see it in his eyes and feels sorry. “Hey, don’t worry, I got a nice one here.” Ahmed shows his brother the big bird with bright eyes and a plume of red and yellow feathers. He gestures to the shop keeper who nods his ok and the boys take the bird out of the cage. “This one looks healthy, I think she can make us some good eggs. We’ll take her.” Ahmed reaches into his pants and pulls out a crumpled pile of colorful bills. He quickly concludes the negotiations with the shopkeeper and they bring the bird home in a burlap sack, squawking the whole way.
As soon as the boys get home they run in the door yelling “Mama we got a perfect chicken, she’s gonna make perfect eggs, come look!” Their mother poked her head out the door of their small one room home and reached over and took a look in the sack. “Perfect, my children, you have found us the perfect chicken. Now go get her into her cage and we can hope for an egg in the morning.” The boys ran in the front of the single room house and straight out the back into an alley. Against the house was a stack of rusty and empty cages. Just as they were getting ready to put the bird in, one of the neighbor boys strolled over. “So, what have you got there Ahmed? Going to give it another try? Birds can’t live here, it’s too dirty and cold back here.” Ahmed looked up at the older boy and just as he did he saw the boy’s younger brothers and sisters form into a large circle around him and Mastouf. “Well why don’t you at least let us see her?” Hesitantly, Ahmed complied and passed the sack around for all of the children to see. After the bird was given a complete tour of all six brothers and sisters Ahmed placed her into her cage with a small cup of corn and a tin filled with water. His mother stepped out into the alley, “Ok, the show is over, time to go home!” And she shooed the other children away.
Chapter 3
Ann Arbor, MI
Alex sits down at the counter of Angelo’s Café with her cup of coffee, in the background just audible over the noise of the small and bustling restaurant she can hear National Public Radio. She bites into her French toast as the news begins to unfold. “Today is the 1835th day since the President declared victory in Iraq Basra and scores of Iraqis die in a suicide bomb attack in central Baghdad
Alex stands, looks out through the old wooden café door and steps out into the sunshine. Well at least today is a glorious spring day. The green leaves on the trees have that intense fluorescent green, the cherry trees visible across East Ann Street have blossoms and all the birds are shouting to their potential mates. Alex smiles to herself as she begins to think of her own potentials when a yell from behind stops her in her tracks. She turns to see her close friend Paula all laughs and giggles. “So, any plans for tonight? I thought we might check out the comedy show down at the union.” Paula has long brown hair, big almond eyes, and an infectious smile. She’s a little heavier than she would like but she this is offset by her generous figure which is on display in her tight low cut brown shirt. “Sure Paula, and are you going to finally stand up and try out your routine, or do we have to wait for some talent scout to catch you trying your lines out in your bathroom?”
Paula has been a wannabe comedienne since the two became best friends in grade school. She has always been the funny one and Alex the serious one. Paula gives Alex balance and without her Alex would have easily lost herself after going through “the tragedy”. Fortunately, this best friend has always been by her side to cheer her up and keep her social. And Alex has done her part for Paula as well. Back in high school when partying was all the rage there were some close calls. If Alex hadn’t yanked her out of those parties and hadn’t pushed her Paula probably never would have finished high school, let alone been accepted to Michigan.
“Ok, I’ll come by around 7:30 and we can grab some food upstairs at Charlie’s before the show”. Paula smiles and with a twinkle in her eyes she takes off in the opposite direction, “Awesome Alex, see you then!”
Alex heads around the corner and into the Med Sciences building. The building was probably modern and clean looking when her dad was in school twenty-something years ago, but now the white-yellow exterior looks a bit sad and shabby under the watchful eye of the new gleaming University Hospital addition. She swipes her ID card and heads in. Medical students are scurrying around looking for labs and lecture halls. The smell of formaldehyde wafts out of the Gross Anatomy lab around the corner. Alex turns into the stairwell and begins her three story climb up to the microbiology floor. The stairwell railings are black painted iron and probably have their own microflora that could represent it’s own publication. She always avoids those railings, who knew what nasty critters had been innocuously carried out of a lab by a careless and sloppy assistant. At the third floor door she swipes her card again and enters the stained linoleum hallway to her lab. A finger print reader and she’s in. The whole thing seamed ridiculous. Ever since 9/11 they added security to all of the labs. This was before Alex’s time but apparently back then they did background checks on everyone, issued secure ID’s and fingerprinted everyone. Alex wasn’t quite sure what of value could have been taken from the Gross Anatomy lab that would bring terrorism to the hills of Ann Arbor but the laid back atmosphere in the labs was quickly replaced by apprehension and paranoia and more than one post doc left to go into a different line of work. Apparently the stress level had relaxed a bit and now the only labs requiring intensive scrutiny and security were those either working with infectious disease or those using radioactive substances. Both were present in Dr. Zack’s lab and so they gave him a secure floor. Funny thing was that any first year engineering student could probably outsmart the security anyways. Most of this stuff was off the shelf at Best Buy.
As Alex walked in she could hear the news again coming from Dr. Zack’s office. The news now was about Iran Iran Ann Arbor
His blue eyes look Alex up and down and he smiles widely. “Well dear, ready for another day in the trenches? We have another sample of lung tissue from that most recent avian flu outbreak in Pakistan. We need new cultures set up and we need to do another trial for lethality and transmission.” Alex lets out a groan. This was going to be another marathon and there was a very good chance she would not make the show tonight.
Whenever the tissue came in from these Asian countries the shipping was usually very sloppy. Last time the specimen was fully rotted because the cooling packs leaked. Dr. Zack’s lab was one of only three in the U.S.
Alex starts to recall the lecture she gave to Dr. Zack’s medical students last term. She was in charge of power point slides in the lab along with just about all the other grunt work. After putting the presentation together Dr. Zack asked her to just go ahead and do the presentation. The whole idea was a bit unorthodox but everything about Dr. Zack is.
The first slide went up on the screen and Alex began the show. “Avian flu” so named because it is influenza virus that is endemic in the bird population but people have been dying from it for a few years now. The virus is scary because the mortality rate can be 80%. We have seen it mostly in Asia because the populations there live in close contact with birds. Every now and then a person or group is exposed to an infected bird, they themselves become infected and more often than not die. There isn’t any treatment except supportive care and no vaccine has been developed yet.
Historically, every twenty years or so, one of the viruses endemic to a different species mutates and enters the human population. Usually the sick, elderly and very young are quite susceptible and die. This is why a cure for the flu is so difficult. New virus types keep on entering the population. Even more scary is that about every eighty years a super flu comes out and kills huge numbers of people. That’s what happened in 1918 and therefore Dr. Zack, the CDC and military have been focusing our research on this bug because we think it is the best candidate for the next bad event.
After the forty minute lecture the students filed out. A couple raised hands with questions but most just quietly moved on. Alex remembers leaving the room, wondering if she was on the correct side of the podium. Her life would have been very different except for one very bad day.
Wednesday, May 18, 2011
A Great Return
I just returned from nearly two weeks in Mexico. I was fortunate to be able to spend such a long and vital time with my family. Usually when I return I'm afraid of what has happened while I was traveling. So, as per usual pattern I had a few anxiety nightmares a couple nights before my return home. The day before I awakened with a rapid heart beat. "What was Monday going to be like?"
I never know if on my return I will be crushed with disaster. The hard part about being a physician is the worrying. Before I leave I want everything tidy. All my patients in good shape. If anyone is sick or not recovering well from surgery I put in extra hours to get them straightened out. Luckily, I work with two excellent doctors that I have enormous trust for. Still, I don't want them to be upset that I left them a bunch of unfinished work. So, before this trip I had everyone in good shape. But, life is unpredictable and the healing arts are just that, art work. So, like I said earlier I get nervous before my return.
But this time was great. I walked in to my office and popped open my laptop to review all of my messages and patient files. Whew! No disasters. I made a few calls, updated people on their test results and renewed a bunch of prescriptions. Lucky for me Monday was a short day of paper work only. I wondered, "What will Tuesday be like?" Tuesday arrived and I started to see my patients. It seemed like everything was working. Everyone seemed to be in great shape. Postsurgical patients were healing, infections were going away, headaches and dizziness were better. A fluke? Nope! Wednesday has been the same. Everyone is doing great. New challenges arrived today but nothing I couldn't tackle. But best of all is that some of my most challenging patients are feeling better, happy and enjoying their regained health.
A great return! These vacations do more than just give me rest. I return with a new set of eyes and a fresh and energetic attitude. And the payback is great. It's hard to explain how much pleasure there is in seeing people responding to my treatment. Sometimes this is the greatest job and today is one of those days!
I never know if on my return I will be crushed with disaster. The hard part about being a physician is the worrying. Before I leave I want everything tidy. All my patients in good shape. If anyone is sick or not recovering well from surgery I put in extra hours to get them straightened out. Luckily, I work with two excellent doctors that I have enormous trust for. Still, I don't want them to be upset that I left them a bunch of unfinished work. So, before this trip I had everyone in good shape. But, life is unpredictable and the healing arts are just that, art work. So, like I said earlier I get nervous before my return.
But this time was great. I walked in to my office and popped open my laptop to review all of my messages and patient files. Whew! No disasters. I made a few calls, updated people on their test results and renewed a bunch of prescriptions. Lucky for me Monday was a short day of paper work only. I wondered, "What will Tuesday be like?" Tuesday arrived and I started to see my patients. It seemed like everything was working. Everyone seemed to be in great shape. Postsurgical patients were healing, infections were going away, headaches and dizziness were better. A fluke? Nope! Wednesday has been the same. Everyone is doing great. New challenges arrived today but nothing I couldn't tackle. But best of all is that some of my most challenging patients are feeling better, happy and enjoying their regained health.
A great return! These vacations do more than just give me rest. I return with a new set of eyes and a fresh and energetic attitude. And the payback is great. It's hard to explain how much pleasure there is in seeing people responding to my treatment. Sometimes this is the greatest job and today is one of those days!
Thursday, May 5, 2011
Bin laden and me, the doctor
I woke up and turned on NPR and discovered the world's most wanted criminal was dead. I listened as they talked about celebrations at Ground Zero and in Washington, D.C.. I didn't have the drive to celebrate, but rather to reflect. For me that fateful day led to the end of my first marriage. I know, that sounds impossible, but I am quite certain it was true.
My wife at the time and I watched those towers fall and the ensuing chaos. We didn't say much. I'm pretty sure that like the rest of the world we were in shock. I felt true fear that some great force was trying to create an overthrow of our government. The whole thing was practically right out of a Tom Clancy novel. I guess it's strange but when the terror stopped that day and we later on found out it was perpetrated by this man and his acolytes from training camps in Afghanistan I felt relieved.
I know that the real terror that was committed wasn't the death of all of those people. The real terror is how each of us dealt with the tragedy. For me I immersed more intensely in work. For my wife, she reevaluated her life and decided I wasn't going to be a part of it. For the past 11 years I have dealt with that terror, the disruption and destruction of my original family unit.
That day in 2001 and the ones that followed were interesting in the office. Either nothing was said about the disaster or people needed someone to talk to . Most were quiet. A few needed me to sit and listen. They asked me questions that were mostly about the future. Future of healthcare, government, our lives. I would reassure them that our country was strong, our people were good, and somehow we as a nation and world would end up stronger and better from this.
Fast forward to the last couple of days. I could sense a change in the office and in people's attitudes but I couldn't exactly identify it. Two of my older patients wanted to talk. Interestingly, they both had similar viewpoints. They didn't feel celebratory. They even thought that we were kind of gloating as a nation about the death of this terrorist. And neither of them felt it would make a significant change in the grand scheme of things.
Once again, I listened, I talked about how disturbing it was that Pakistan was probably not the ideal partner. But, mostly I talked about how this showed that we as a nation were growing and maturing in some ways and in others we were still like children. All this time, in the back of my mind was the havoc that was wreaked on my life from that fateful day.
But, also in my mind was the wonderful change my life had taken. For now I have the most beautiful and wonderful wife who loves me and cares for me. We have an absolutely phenomenal child who is bright, beautiful and a joy to be with. And, my relationship with my eldest daughter is now stronger than I can remember.
So, in retrospect, I cannot celebrate the death of this monster for I have very mixed feelings from what he did to me and my country and my world. But, I do know that I and we are stronger and better than we were.
My wife at the time and I watched those towers fall and the ensuing chaos. We didn't say much. I'm pretty sure that like the rest of the world we were in shock. I felt true fear that some great force was trying to create an overthrow of our government. The whole thing was practically right out of a Tom Clancy novel. I guess it's strange but when the terror stopped that day and we later on found out it was perpetrated by this man and his acolytes from training camps in Afghanistan I felt relieved.
I know that the real terror that was committed wasn't the death of all of those people. The real terror is how each of us dealt with the tragedy. For me I immersed more intensely in work. For my wife, she reevaluated her life and decided I wasn't going to be a part of it. For the past 11 years I have dealt with that terror, the disruption and destruction of my original family unit.
That day in 2001 and the ones that followed were interesting in the office. Either nothing was said about the disaster or people needed someone to talk to . Most were quiet. A few needed me to sit and listen. They asked me questions that were mostly about the future. Future of healthcare, government, our lives. I would reassure them that our country was strong, our people were good, and somehow we as a nation and world would end up stronger and better from this.
Fast forward to the last couple of days. I could sense a change in the office and in people's attitudes but I couldn't exactly identify it. Two of my older patients wanted to talk. Interestingly, they both had similar viewpoints. They didn't feel celebratory. They even thought that we were kind of gloating as a nation about the death of this terrorist. And neither of them felt it would make a significant change in the grand scheme of things.
Once again, I listened, I talked about how disturbing it was that Pakistan was probably not the ideal partner. But, mostly I talked about how this showed that we as a nation were growing and maturing in some ways and in others we were still like children. All this time, in the back of my mind was the havoc that was wreaked on my life from that fateful day.
But, also in my mind was the wonderful change my life had taken. For now I have the most beautiful and wonderful wife who loves me and cares for me. We have an absolutely phenomenal child who is bright, beautiful and a joy to be with. And, my relationship with my eldest daughter is now stronger than I can remember.
So, in retrospect, I cannot celebrate the death of this monster for I have very mixed feelings from what he did to me and my country and my world. But, I do know that I and we are stronger and better than we were.
Wednesday, April 27, 2011
Virestorm-Let the adventure begin
Prologue
September 22, 1918, Vilosplad , Russia
The gray air filled with the moans of those still alive. The barely surviving were carrying the dead, as they were coughing and wheezing through the rain. The old and the young already gone. Those lucky enough to pass in the early days were buried with respect. Now, large unmarked holes marred the landscape. Filled with the dead in the tattered clothes they ended their lives in. No one left to clean them and dress them. No one left to attend to their final religious rites. The town priest, old and weak before the plague, died soon after the second wave of disease. The third wave though, was the worst. Now they we’re losing the healthy ones. The ones who were supposed to rebuild the community, write about their lives and to remake their future. Just one more blow after a decade mostly filled with war and hate.
Anatoly gazes upon his fellow villagers, or rather, what was left of them and thought “Will there even be one to remember who we were?” The pain felt too great. In the past weeks he had buried his wife, his children, even his grand children. And now he could feel the disease coursing through his own body. And now, even he shakes with fevers, a racking cough, and fatigue. Oh the fatigue. He used to be able to carry two sacks of flour on each shoulder and walk miles. Now, even the weight of his wasted self he can barely carry. No, it can’t be long before it’s his turn for that big hole of hell in the ground. Maybe, if there is something resembling a god, he will be with his lovely Ana once again.
From a hilltop little Ivan watches. No, he won’t go near them. His mother sent him away when she heard about the disease from the next town. She sent him away with bags of barley, dried meat and fruit. She told him not to come down to the village. No matter how loud the people screamed, no matter how much he missed his family and friends. He was to stay away, hide, and she implored him don’t come back until the winter comes. After the ground has frozen it might be safe. “But not a moment sooner.”
Ivan can see an old man shuffle to the graves. He stands over them for a long minute. Swaying to and fro. The rain picks up and its hard to see and then the old man is gone. Ivan turns around and hikes back into the hills, to his makeshift home, to wait for winter to come.Chapter 1
Spring 2008, Siberia
Two men step out of a black Mercedes sedan. One, very Russian looking. He is heavy, short, thick necked and thick waisted. He scans the horizon with his small dark eyes and permanent scowl. The other man is tall and very thin. Olive skin and large brown eyes set him apart from the usual visitors here. He is very Middle Eastern looking and very out of place. He walks around to the trunk and removes a heavy sack. He turns to the Russian and with a tilt of his head gestures toward an old man, stoop shouldered in tattered brown clothing. The Russian walks over to the old man and they begin to talk in Russian. They seem to be negotiating. There is some finger pointing. The Russian looks at the old man, angry now. He looks as if he might break him in two. Finally, with a grunt the Russian pulls out a fold of bills. The old man stares at the crisp American dollars as he peals off a few and hands them to the old man. The old man seems wary but gestures them forward.
All three depart the road and hike along a meadow path. The grass is bright green, the meadow erupting in wild flowers. They travel over a hill. Down below is a collection of crumbling buildings. The old man stops. He will not go any further. He points to what is left of the old village. His rheumy eyes look up at the two men. He waits. The Russian reaches into his pocket. He begins to remove his wallet when a loud crack erupts. The old man falls backward with a hole between his eyes and a look of total acceptance. The Middle Eastern man puts his gun away, puts the strap of the sack on his shoulder and begins to hike down the hill toward the abandoned village.
The two men enter the remains of a very old village. The buildings have been abandoned long ago, the roofs caved in and the fences collapsed. They continue down what must have been at one time the main road. The road makes a turn to the right and behind a crumbled fence is a barely visible marker. They begin hiking through brush and bramble over ancient and toppled headstones. Toward the back is a large mound. There is no marker. The Russian turns to the Middle Easterner and nods. The slender man sets down the sack, unzips it and begins pulling out items. He puts on a plastic suit, gloves, mask and goggles. Next he removes a shovel and begins to dig. The earth is soft now that the frost has melted and the ground is still moist. He digs rapidly through the soft earth and then the ground becomes hard again. He has reached the layer where the frost never melts. He pulls out a pick and swings at the ground to loosen the earth. Hard clumps come up and after toiling for a little while he starts to see shreds of gray and brown cloth. He slows his pace and begins to pick at the earth with finer tools. Soon he has uncovered two bodies one lying across the other. He gets very serious now. He carefully removes the clothing from the torso of a man. He gently cleans the soil away.
For Ahmed knows that great respect must be paid to the dead. Even the infidels are to be treated with respect, even those abandoned and mistreated by their own. He turns to the East and makes a nearly silent prayer before resuming his task. He removes a scalpel and makes an incision on the dead man’s right side. He cuts through the rib cage and inserts a device to spread the ribs. Next he reaches into his sack and removes a thermos looking container. He opens the container by releasing two latches and inside is a second container with a screw top.
Next he changes his gloves and dons two layers. He reaches into the chest and feels the hard frozen lung tissue. Perfect, he thinks to himself. He removes a new knife with a long serrated edge and cuts into the tissue. He is able to remove a piece the size of a tennis ball. He looks at it in the light and can see that the dark brown tissue is filled with a thick frozen yellow liquid. He carefully quarters the flesh and places it in the container. He screws the cap on and applies an adhesive tape around the lid. Next he washes the receptacle down with pure alcohol. Again he changes his gloves. He then places the container into its parent and seals the latches. He reaches into his bag and removes an object that looks like a squat cylinder with a thread top. He screws this into the thermos and twists a valve. A hiss is emitted and the exterior of the thermos quickly frosts over. He puts on a pair of insulated gloves and places this into a collapsible insulated bag that he removed from the sack. Next he gently places a white sheet over the body and says a prayer for Allah to accept the soul of this infidel for the sacrifice he has made for the nation of G-d.
He then covers the bodies with the dirt. When he is done he removes his protective gear. He asks the Russian to turn away and he then removes his clothing. He puts all of this in a pile and soaks it with lighter fluid and ignites it. When the fires is out and he has put on fresh clothes he lays down a prayer mat and facing East prays thanks to Allah for this great day.
The men hike back to the Mercedes and depart.
Monday, April 25, 2011
Slaying the beast
In my last article I introduced you to "the hidden beast" in health care which is the fact that we lack enough physicians in our country to handle our growing and aging population. I may be a bit pretentious in claiming that I have ideas on how to slay the beast but I do have some very specific ideas. These ideas will require patients, physicians and the various insurance companies to undergo a dramatic shift in how we interact.
First, we must accept that there is no way we can create enough healthcare providers to meet our upcoming demands. How do I know this? Training a physician takes approximately twelve years after high school on average. If we start today, and we should, encouraging kids in junior high and high school to begin thinking about medicine and mentoring them through the education process and simultaneously expanding medical school enrollment to allow for this influx, under the best of circumstances we will begin to bring these young doctors to you in 2025. Now, these kids are pretty bright and I think they probably read the same articles I do that Medicare will go bankrupt somewhere around 2018. I wonder how many of them are interested in being professional physician volunteers. By the way, they will probably owe somewhere in the neighborhood of $500,000 for this privilege.
Ok, so that idea may not work. Well, we could just make the existing doctors work harder. We can continue dropping reimbursements so they will be incentivized to work harder and see more patients. Oh, wait, that's what Medicare has been doing for the last 10 years and it hasn't worked. On top of this, I hear patients everyday complaining their doctor has no time for them and how can an office visit last only five to ten minutes. I guess people might be even more disappointed if the visit lasted one to three.
Perhaps we need to think a little "outside the box". I suggest we try to make our doctors more efficient and incentivize this efficiency. For example, attorneys, accountants, and countless other professionals are compensated for services that are not face to face. Did you know that insurance companies have created reimbursement codes for a doctors phone calls or emails to a patient? But, here's the zinger, they pay zero dollars for this service. Every physician deals with this issue differently. The majority will not provide any significant treatment or planning over the phone or by email but rather require face to face contact. Many will notify patients of lab results and x-rays by phone, or at least have their office staff do it. Some will require a return appointment to discuss results. I suspect it really depends on how busy they are.
Furthermore, the forward thinking members of our congress created the Health Information Portability and Accounting Act of 1996, better known as HIPAA. Part of this legislation prevents your doctor from emailing you if either email company does not use encrypted secure servers. If your medical information makes it into the wrong hands the fines for your doctor can be tens of thousands of dollars. I suspect this may represent a bit of a disincentive to your doctor as well.
I suggest that compensation for non face to face care be established and that the government "encourage" email companies such as Google and Hotmail to have special servers that are for the delicate transfer of this information. Just by enabling me to email a patient that his x-ray was fine would be a huge improvement in efficiency.
Now let's get a little bit controversial. Many of you are thinking what about a greater use of physician's assistants (PA's) and nurse practitioners (NPs)? I think that this is a great idea, but, we have to recognize the skill levels that each of us has. PA's and NPs typically have two years of training beyond their undergraduate degree. They are very well suited to managing routine health issues including annual check ups, uncomplicated diabetes and hypertension care, treatment of routine respiratory infections, etc.. Unfortunately, many doctors use these vital assistants as substitute physicians and place responsibilities on them that are inconsistent with their experience and training. On the other hand, I think that it is a terrible waste of resources to use highly trained physician's to do these activities.
In fact, I find it ironic that over the last twenty years there has been a huge push for physicians to become primary care providers. We are taking our best and brightest and encouraging them to focus on the least complex care. In fact, if your doctor sees you for five minutes to tell you that you have a viral upper respiratory infection he is paid practically the same amount as if you come in coughing, and wheezing with pneumonia. Yet the two situations result in a very different amount of complexity and time required.
I would suggest we establish clear expectations on patients with appropriate incentives in the way of copays and deductibles that pushes them toward PA's and NPs for routine care and incentivizes the doctor to pick up the most complex patients they can. In fact, I suggest that we push more of our doctors to specialize. There is far too much information for someone to handle in a general way. When I was in medical school there were about five commonly used blood pressure medications. Now there are twenty categories each having dozens of medications. In fact, many doctors trained in primary care fields have left their practices to become hospitalists. Hospitalists get to focus on hospitalized patients, i.e. those that are the most ill, because the care is rewarding, the hours are structured, and once cured the patients return to their original practitioner. This model could be expanded with a far better structure for reimbursements.
In the ideal world easy routine care could be provided by a PA or NP. Those who don't respond would see a physician and in some situations one who has specialized in the area of concern and get placed on appropriate care. Once cured or on a treatment plan the patient would then return to their original caregiver, freeing up the physician/specialist to move on to the next complicated case. In addition, the PA or NP would have lower level assistants reporting to them who routinely communicate with patients to make sure that they are taking their medications as well as setting up even lower level visits for just checks on those issues that need chronic monitoring.
The entire health care system would be changed from it's current design which is flat and wide to a pyramid with the doctor at the top and all of the other caregivers below. By doing this we could successfully do more with less. And, I suspect, we may even save a few dollars. I know that what I suggest is radically different from what we are used to. In fact, some people may feel offended at my assessment. But, that is why I have established this blog. I encourage anyone to help come up with better ideas. And perhaps if we are very lucky we can help change this situation.
Best of luck to us all in slaying the beast!
Return on Wednesday and I will post the first chapter of "Virestorm". I am hoping to provide an interactive entertaining way to share a story that I have been working on in pieces for the past year. I will use your input to help steer the characters and action to a hopefully exciting finale.
First, we must accept that there is no way we can create enough healthcare providers to meet our upcoming demands. How do I know this? Training a physician takes approximately twelve years after high school on average. If we start today, and we should, encouraging kids in junior high and high school to begin thinking about medicine and mentoring them through the education process and simultaneously expanding medical school enrollment to allow for this influx, under the best of circumstances we will begin to bring these young doctors to you in 2025. Now, these kids are pretty bright and I think they probably read the same articles I do that Medicare will go bankrupt somewhere around 2018. I wonder how many of them are interested in being professional physician volunteers. By the way, they will probably owe somewhere in the neighborhood of $500,000 for this privilege.
Ok, so that idea may not work. Well, we could just make the existing doctors work harder. We can continue dropping reimbursements so they will be incentivized to work harder and see more patients. Oh, wait, that's what Medicare has been doing for the last 10 years and it hasn't worked. On top of this, I hear patients everyday complaining their doctor has no time for them and how can an office visit last only five to ten minutes. I guess people might be even more disappointed if the visit lasted one to three.
Perhaps we need to think a little "outside the box". I suggest we try to make our doctors more efficient and incentivize this efficiency. For example, attorneys, accountants, and countless other professionals are compensated for services that are not face to face. Did you know that insurance companies have created reimbursement codes for a doctors phone calls or emails to a patient? But, here's the zinger, they pay zero dollars for this service. Every physician deals with this issue differently. The majority will not provide any significant treatment or planning over the phone or by email but rather require face to face contact. Many will notify patients of lab results and x-rays by phone, or at least have their office staff do it. Some will require a return appointment to discuss results. I suspect it really depends on how busy they are.
Furthermore, the forward thinking members of our congress created the Health Information Portability and Accounting Act of 1996, better known as HIPAA. Part of this legislation prevents your doctor from emailing you if either email company does not use encrypted secure servers. If your medical information makes it into the wrong hands the fines for your doctor can be tens of thousands of dollars. I suspect this may represent a bit of a disincentive to your doctor as well.
I suggest that compensation for non face to face care be established and that the government "encourage" email companies such as Google and Hotmail to have special servers that are for the delicate transfer of this information. Just by enabling me to email a patient that his x-ray was fine would be a huge improvement in efficiency.
Now let's get a little bit controversial. Many of you are thinking what about a greater use of physician's assistants (PA's) and nurse practitioners (NPs)? I think that this is a great idea, but, we have to recognize the skill levels that each of us has. PA's and NPs typically have two years of training beyond their undergraduate degree. They are very well suited to managing routine health issues including annual check ups, uncomplicated diabetes and hypertension care, treatment of routine respiratory infections, etc.. Unfortunately, many doctors use these vital assistants as substitute physicians and place responsibilities on them that are inconsistent with their experience and training. On the other hand, I think that it is a terrible waste of resources to use highly trained physician's to do these activities.
In fact, I find it ironic that over the last twenty years there has been a huge push for physicians to become primary care providers. We are taking our best and brightest and encouraging them to focus on the least complex care. In fact, if your doctor sees you for five minutes to tell you that you have a viral upper respiratory infection he is paid practically the same amount as if you come in coughing, and wheezing with pneumonia. Yet the two situations result in a very different amount of complexity and time required.
I would suggest we establish clear expectations on patients with appropriate incentives in the way of copays and deductibles that pushes them toward PA's and NPs for routine care and incentivizes the doctor to pick up the most complex patients they can. In fact, I suggest that we push more of our doctors to specialize. There is far too much information for someone to handle in a general way. When I was in medical school there were about five commonly used blood pressure medications. Now there are twenty categories each having dozens of medications. In fact, many doctors trained in primary care fields have left their practices to become hospitalists. Hospitalists get to focus on hospitalized patients, i.e. those that are the most ill, because the care is rewarding, the hours are structured, and once cured the patients return to their original practitioner. This model could be expanded with a far better structure for reimbursements.
In the ideal world easy routine care could be provided by a PA or NP. Those who don't respond would see a physician and in some situations one who has specialized in the area of concern and get placed on appropriate care. Once cured or on a treatment plan the patient would then return to their original caregiver, freeing up the physician/specialist to move on to the next complicated case. In addition, the PA or NP would have lower level assistants reporting to them who routinely communicate with patients to make sure that they are taking their medications as well as setting up even lower level visits for just checks on those issues that need chronic monitoring.
The entire health care system would be changed from it's current design which is flat and wide to a pyramid with the doctor at the top and all of the other caregivers below. By doing this we could successfully do more with less. And, I suspect, we may even save a few dollars. I know that what I suggest is radically different from what we are used to. In fact, some people may feel offended at my assessment. But, that is why I have established this blog. I encourage anyone to help come up with better ideas. And perhaps if we are very lucky we can help change this situation.
Best of luck to us all in slaying the beast!
Return on Wednesday and I will post the first chapter of "Virestorm". I am hoping to provide an interactive entertaining way to share a story that I have been working on in pieces for the past year. I will use your input to help steer the characters and action to a hopefully exciting finale.
Saturday, April 23, 2011
The hidden beast
Watching and listening to the news lately one would think that all of the troubles in healthcare can be solved either by having everyone purchase insurance coverage or finding a funding source and giving it to them. I find it remarkable that the most "brilliant" economists keep on missing one of the most important factors in health care delivery. Who is going to provide the care to all of the newly expanded health care rolls? They somehow have the mistaken belief that if one has a health insurance card all will be well.
Unfortunately, they have forgotten one very important factor. While our population ages and shifts into a larger and larger number of people who require ever greater care we have not had any significant growth in physicians in decades. There was a bump in medical school enrollment in the 80's but that group, which I am part of, is established and unlikely to significantly increase it's workload.
For the past 20 years the best and brightest have chosen fields like investment banking and computer engineering. These fields have had dramatically greater compensation growth. In fact in the past 10 years physician compensation has had virtually zero increase so relative to inflation the income has gone backwards. This insight has not been lost on the young men and women in college. So, while our population grows our number of graduating medical professionals are hardly keeping up.
I predict that in the next 3 to 5 years this issue will hit a break point. Those with an existing physician will start off doing fine but if you don't have a doctor caring for you it may be near impossible to find one. This has already started happening in the primary care fields but it will extend to specialty care as well. In addition, there is a large number of doctors 60 to 70 years old who have delayed retirement the last 5 years. But, as the economy rebounds the doctors who are near retirement will see their retirement investments grow and become large enough to allow them to retire. This will put a further strain on an already highly stressed system.
In fact, as this group of doctors goes in to retirement a large number of people will be looking to establish relationships with new physicians. But they will be in direct competition with a younger group of the aging population as well as newly insured. I predict that this will create a very interesting dynamic that hasn't occurred in the country in generations. We won't need to worry about death panels or insurance denials of care because a large number of people won't be able to make it into an office.
In fact, we will see a huge shift to using the emergency room as a site of primary care. This has already occurred for the uninsured and under insured population but this will become typical for most everyone. I predict that insurance companies will begin to aggressively recruit doctors to their panels. They will require exclusive agreements and will give special packages to the doctors to recruit them in. This will likely shift another segment of the population into the ER. These will be patients who no longer can see their doctor because he is a provider for only a finite number of insurances.
The state and federal governments will be faced with an unprecedented issue. How to provide care for literally millions of people. We might look to recruiting doctors from overseas but as the economies in Asia begin to grow I suspect the doctors will sense opportunities for success in their homelands and will choose to avoid the chaos here.
Is there an answer? I doubt that there will be any easy way to solve this but I will begin to offer some ideas in my next blog "Slaying the Beast".
Unfortunately, they have forgotten one very important factor. While our population ages and shifts into a larger and larger number of people who require ever greater care we have not had any significant growth in physicians in decades. There was a bump in medical school enrollment in the 80's but that group, which I am part of, is established and unlikely to significantly increase it's workload.
For the past 20 years the best and brightest have chosen fields like investment banking and computer engineering. These fields have had dramatically greater compensation growth. In fact in the past 10 years physician compensation has had virtually zero increase so relative to inflation the income has gone backwards. This insight has not been lost on the young men and women in college. So, while our population grows our number of graduating medical professionals are hardly keeping up.
I predict that in the next 3 to 5 years this issue will hit a break point. Those with an existing physician will start off doing fine but if you don't have a doctor caring for you it may be near impossible to find one. This has already started happening in the primary care fields but it will extend to specialty care as well. In addition, there is a large number of doctors 60 to 70 years old who have delayed retirement the last 5 years. But, as the economy rebounds the doctors who are near retirement will see their retirement investments grow and become large enough to allow them to retire. This will put a further strain on an already highly stressed system.
In fact, as this group of doctors goes in to retirement a large number of people will be looking to establish relationships with new physicians. But they will be in direct competition with a younger group of the aging population as well as newly insured. I predict that this will create a very interesting dynamic that hasn't occurred in the country in generations. We won't need to worry about death panels or insurance denials of care because a large number of people won't be able to make it into an office.
In fact, we will see a huge shift to using the emergency room as a site of primary care. This has already occurred for the uninsured and under insured population but this will become typical for most everyone. I predict that insurance companies will begin to aggressively recruit doctors to their panels. They will require exclusive agreements and will give special packages to the doctors to recruit them in. This will likely shift another segment of the population into the ER. These will be patients who no longer can see their doctor because he is a provider for only a finite number of insurances.
The state and federal governments will be faced with an unprecedented issue. How to provide care for literally millions of people. We might look to recruiting doctors from overseas but as the economies in Asia begin to grow I suspect the doctors will sense opportunities for success in their homelands and will choose to avoid the chaos here.
Is there an answer? I doubt that there will be any easy way to solve this but I will begin to offer some ideas in my next blog "Slaying the Beast".
Thursday, April 21, 2011
Time to share
Today begins my journey to share with you my thoughts and feelings about health and healthcare and how it relates to each and every one of us. For several years I have had patients, friends and family ask about my opinion regarding health policies and health care. Often times they are scared about something they read in the newspaper or heard on the radio or television. I'm not surprised about the fear and confusion since most of what is presented is slanted in one angle or another.
In fact, more than once a patient has turned to me with tears in their eyes and asked what will happen to their insurance or whether I will be available to help them after new changes occur. Usually, these are the moments I slow everything down and take the time to explain from my perspective how I think events will play out. Each time this happens I wonder how many others are out there scared and confused and wanting an answer from someone they trust who is impartial and understanding.
So that leads to why I am writing this post today and why I am going to continue doing this into the future. My plan is to make commentaries about various aspects of what is occurring in both the macro national and world environment as well as the micro personal environment of myself. I hope to relate to my readers and to share stories and anecdotes about success as well as some of the scariest and even strangest moments I have experienced.
Each time you look at one of my new posts I hope to share with you a new idea or thought. I hope that if my comments move you that you will share that with me. I also look forward to you asking questions for me to ponder and answer. Together I hope we can all grow and learn together.
In fact, more than once a patient has turned to me with tears in their eyes and asked what will happen to their insurance or whether I will be available to help them after new changes occur. Usually, these are the moments I slow everything down and take the time to explain from my perspective how I think events will play out. Each time this happens I wonder how many others are out there scared and confused and wanting an answer from someone they trust who is impartial and understanding.
So that leads to why I am writing this post today and why I am going to continue doing this into the future. My plan is to make commentaries about various aspects of what is occurring in both the macro national and world environment as well as the micro personal environment of myself. I hope to relate to my readers and to share stories and anecdotes about success as well as some of the scariest and even strangest moments I have experienced.
Each time you look at one of my new posts I hope to share with you a new idea or thought. I hope that if my comments move you that you will share that with me. I also look forward to you asking questions for me to ponder and answer. Together I hope we can all grow and learn together.
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