Thursday, May 24, 2007

Easy or Hard?

Let's play "easy or hard." What would you do?
1. Mom brings in a 2-year old girl. The girl has been having a green runny nose for three days. She has been running a low grade fever (under 100). She is eating (though not as much as usual), sleeping, and still playing. She also attends daycare. Physical exam reveals mild nasal congestion; lungs are clear, eardrums look normal. Do you:
a) (Easy) prescribe amoxicillin for "sinusitis" so she can go back to day care and prevent mom from calling you in 3 days to say, "she's still not better!"
b) (Hard) let mom know that green rhinorrhea does not necessarily mean a bacterial infection, particularly in an upper respiratory infection of a few days with no other significant symptoms (e.g., fever, lethargy, findings on physical exam); explain that antibiotics are not indicated, discuss the role of over-the-counter remedies, encourage fluids, rest, nasal saline drops, and a humidifier or vaporizer; and ask that the mom call back in a few days if symptoms have not improved or if she is worsening.

2. Dad brings in a 6-year old boy. The boy was reportedly diagnosed with asthma by another pediatrician 4 years ago. He takes albuterol in a nebulizer when he gets sick. His "breathing attacks" consist of a junky rattle in his chest with coughing. He has no problems with breathing or coughing when he is not sick. He is now out of albuterol and wants a refill. On exam, his lungs are clear. Do you:
a) (Easy) write the refill and send them on their way
b) (Hard) explain that his current condition sounds more like a simple cold than an asthma attack; advise the father to use a humidifier at nighttime, watch the child's breathing for signs of retractions or respiratory distress; educate about the side effects of albuterol; and hold the refill unless symptoms change or progress
c) (Very Hard) same as "b" but also perform pulmonary function tests in your office to more definitively evaluate the symptoms; go over the results with dad and explain what it means and why

I could go on, but you get the idea. The Hard choices are good medicine; they bring the patient into the care, produce better outcomes, educate for the future, and are supported by clinical data and experience. But the Hard choices take time. They rarely, if ever, lead to better reimbursement (in fact, according to proper CPT coding, the simple act of writing a prescription can potentially increase the "complexity" of the visit and lead to mo' money; therefore, the education costs me both time and money!). Some patients don't want the education; they just want the prescription (this is called "convenience," and it's why CVS is betting that people will prefer to go to a nurse practitioner in a minute clinic instead of their regular doctor; it's not the best care, but that's irrelevant...)

It's been said that our current system therefore rewards mediocrity. Pay-for-performace (P4P) clearly isn't the answer, if only because "performance" means different things...and to a payor, it usually means "saving money." "Quality" is much more difficult to define, or at least measure.

I've heard that we should let the free market decide. Lawyers are free to charge whatever they want. The best lawyers charge the most. Can't afford it? Don't like it? Fine, see a cheaper lawyer. You'll get adequate representation. Which is fine for drawing up a will or contesting a small claim. Is that acceptable for multi-million dollar liability lawsuits? How about first-degree murder cases? Without giving an answer to that question, let's extend it to medicine. Yes, I know, concierge care is already a small example of this taking place. Does this mean that the poor are effectively excluded from the best care? Is that fair? Is that just? Is that simply the consequence of a capitalistic health care system?

Easy and hard, indeed. No answers here, not yet. Perhaps the lack of standardized incentives is actually an advantage: let everyone determine for themselves what they really do want. You want a quick scrip and no fuss? Find a doctor like that, or go to a minute clinic. You want 24-7 concierge care and 2-hour visits? Fine, just pony up. You want a doctor that takes time to listen, offers quality care, matches your personality? Listen through the grapevine and see who your friends and neighbors recommend. Don't like Doctor A? Go see Doctor B, maybe she's better. Everyone gets paid, everyone gets what they want--or at least compromises to get "good enough". So maybe the status quo is the best idea after all.

Wednesday, May 23, 2007

Towel Day

I just learned that May 25 (this Friday) is Towel Day.
Apparently it is in tribute to Douglas Adams and The Hitchhiker's Guide to the Galaxy.
As useful as a towel might be, I don't think I'll be bringing mine to work--I don't think my clientele would appreciate the reference--but I do think it's a cool idea and wanted to spread the word.
So there, I just did.

Monday, May 7, 2007

Lady in the...What? Er...

Watched M. Night Shyamalan's "Lady in the Water" last night.
Felt inspired to write a haiku about it:

Dear Shyamalan,
I gave your film a good try.
Want my two hours back.

L. commented that it would have made a pretty good anime, with teenage characters. But it's not that, so I warn you: it's dreadful schlock. I would urge you, watch something else instead.
Just to avoid being Mr. Negativity, I'll even recommend two recently seen, better movies:
1) "Flushed Away"
Laugh-out loud funny, great Aardman animation (you know, Wallace and Gromit?) Kate Winslet provides a great voice to "Rita."
2) "Tom Dowd and the Language of Music"
A little-seen documentary about a little-known music engineer who revolutionized the music industry and who worked alongside many of the greatest artists in rock and roll, soul, jazz, and more. And he seems like a really cool guy to boot.

Next on the Netflix list: Little Miss Sunshine. Dr. Dork has recommended it, so it must be good.

That's all for this week; until next time, we'll see the movies.

Thursday, May 3, 2007

Katrina in the News

1. From Kevin, M.D.:
Physicians at West Jefferson Medical Center in New Orleans are suing the state of Louisiana for $100 million in uncompensated care after Katrina.
I'm not sure a lawsuit is going to work, but I do admire their chutzpah. Because I don't see the state or federal governments giving any money willingly.
2. From the always astute Dr. Hebert:
The Washington Post reported this week that the federal government declined over $800 million from foreign governments after Katrina. Yes, you heard right. It was offered, and George W. said "no thanks."
Yet our government says it has no money for health care in the Katrina zone (or for waiving the Stafford Act's 10% local match, despite that having been the case for both 9/11 and Hurricane Andrew).
And of course, we have billions and billions for the Army in Iraq, but that's another story.
Which leads to our third and last item for today...
3. President Bush's veto on the troop funding bill was the lead item on the news a day ago. But a tip of the hat to the New Orleans Fox affiliate (Fox 8) for pointing out that the vetoed bill contained more than military matters.
In fact, H.R. 1591 contained billions of dollars for additional Katrina relief.
So yet again, the fate of the Gulf Coast is tied to the Gulf War, and not for the better.
As Nathan McCall said, Makes Me Wanna Holler.