No Co-Pays Save Money!
Read’em and weep, common logic. If you drop co-pays for the sickest and most at-risk people, you save tens of thousands of hospitalizations and thousands of ED visits. A RAND study.
or
Read’em and weep, common logic. If you drop co-pays for the sickest and most at-risk people, you save tens of thousands of hospitalizations and thousands of ED visits. A RAND study.
Solving power-law social problems. I wonder how this would apply to malpractice (where very few doctors account for most of the lawsuits) or health care spending (where ~20% of patients account for ~80% of expenditures).
February 9th, 2006Mr. Jones has orthopnea secondary to pulmonary edema secondary to congestive heart failure secondary to ischemia secondary to a prior MI secondary to diabetes secondary to obesity secondary to poor diet and exercise regiment secondary to poor access to healthy foods secondary to poverty.
So what killed him, the heart failure, or the poverty?
Can I specialize in weird diseases? I love this stuff.
February 11th, 2006Set to the tune “Ho” by Ludacris (which I totally loathe, but hey, I’m on call tonight).
Who’s full code?
Who’s full code?
Who’s full code?
I said that you’re full code.
Rinse and repeat.
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Flawed and unethical, but I bet it would work:
You would’ve thought the Terry Schaivo thing would’ve done this already, but I seem to get all the patients who have no idea what they want. Just last night, an elderly Hispanic man was admitted for possible heart failure and possible heart attack, and after a lengthy discussion about code status, he tried to give me this innocent little indecisive giggle-shrug-smirk, as if I asked him what type of food he wanted to eat for dinner and just wanted to be agreeable. This ain’t one of those types of questions. You need an answer.
On a more ethical but medically ethical topic, some people propose making the organ donor system an opt-out system, where one would automatically be consenting to donate their organs unless they specifically said they didn’t want to.
*A person’s code status tells the health care system what he or she would like done if their heart stops or lungs stop working–would they like everything done (full code) at one extreme, or would they like no measures taken (DNR, DNI – do not resuscitate, do not intubate). You can pick any level of code status, and have specific parameters as well.
A new cancer blog to keep track of new treatments, because I sure can’t keep up. From an MD/PhD student @ Temple.
February 13th, 2006The bf’s interpretation of me, with scrubs, white coat, and stubble after coming home post-call.
The hospital I’m at has been on divert status multiple times this month (this is not uncommon). That basically means that the ED is full, and can’t accept any more patients. For us, it’s also worked out to mean that our entire hospital is full, including the ICU. There are no open spots. Anywhere.
This prevents surgeries from happening (because there’s no place to put the patients for monitoring after the surgery), and it prevents truly sick people that walk into the ED from getting hospitalized, too. Our schedulers and case workers and discharge planners knock on our doors daily, desperately seeking patients who might be going home. And with our aging population, I really can’t see this getting any better. Nursing shortages make this worse, because of staffing, especially on the weekend, open beds can’t always be turned into patient beds, because of nurse to patient ratios.
This obviously brings up something of an ethical dilemma, where the lofty goals and aspirations of perfect medicine hit the limited resources pavement. There are several people in the ICU who have been there for as much as 8 months or even a year–in comas, on respirators–with little hope of improvement. Yet their living wills insist that they remain on a ventilator, or their family members insist–even despite the patient’s own declared wishes. And so they remain. Then there are others who come back time after time with the same serious problem, sometimes self-induced.
I could easily argue this point either way, and where you stand probably boils down to where you sit on issues of individual or group mentality. Should we do what’s best for any one individual, at the possible cost to the group, or should we sacrifice an individual for the good of the group? (I myself am a total hypocrite, preferring the group mentality in theory, but the individual mentality when it comes to my own health.)
I guess I mainly worry that this problem won’t just go away, and that whatever solution we come to will be one decided either at the last minute, or will be decided based on the most unethical of deciding factors: money. There’s of course an alternative I haven’t discussed here: just build more hospitals, more nursing homes, more clinics, and try to squeeze everyone in, but that will probably just lead to worse nursing and doctor shortages, and lead us deeper into the red.
Any of my answers turn my stomach, so I guess it’s up to choosing between the lesser of two evils.
I don’t particuarly like any of these for many reasons. You can’t arbitrarily sign a death sentence for a person, and you can’t take away a person’s hope so quickly. I don’t know what’s going to happen, but it really, really frightens me.
Valentine’s Day Grand Rounds are up!
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My interns and residents had been talking for weeks about how bad a code situation is, and so when the patient was found unresponsive in his hospital bed today, I figured it’d be neat to go watch. Neat being my Hollywood, glam and glitz, heroic understanding of a code; terrifying would probably fit better. Yes. I figured it’d be terrifying to go watch.
I was amazed at the scene when I arrived, watching from outside the door. I got there only 10 seconds after the Code 66 had calmly been announced overhead (Code Blue scares patients, I guess), and already 25 people were in the room, with supplies, the crash cart, and it was loud. About 8 people were actively around the patient, with others supporting the 8, while some other people were trying to move the patient in the next bed out of the room. I did my best to stay at the periphery, out of the way, and help out when I could. People were quietly talking about how the patient was found, that he was supposed to be discharged today–and who knows where the rumor mill went from there.
A small woman was doing CPR on the gigantic patient (and luckily soon switched with a much larger male nurse), while others were checking pulses or trying to configure the defibrillator. Interns and residents were trying to start femoral lines, palpating weak pulses that trickled by with each chest compression. Two people were bagging the patient with oxygen. The ICU fellow was calling for meds and thinking aloud (I would soon learn the 5 H’s and 5 T’s), while the intern responsible for the patient was announcing the patient’s morning labs and vital signs (“K was 3.6 this morning! Blood pressure was 110/65!”), all of which were stable and within normal limits. The pharmacist was doling out medications from her kit as fast as they were being called for.
Toward the end, the senior resident responsible for the patient was in tears, and the room grew more quiet, with fewer audible voices drowning out the sounds of the code equipment and the oomph of each chest compression. There were fewer looks at the patient, and more at the clock. The pharmacist announced the passing time. “Four minutes since arrest” became “nine minutes” became “fourteen minutes” became finally “twenty minutes,” and the patient was pronounced dead.
“The key is to stay calm,” my resident told me. I told her I didn’t think I’d ever be calm in a situation like that, and she shared her secret: “I just assume the patient is already dead, and anything I do can only help them.” I think she may be right.
A great health care policy quiz about health care in other countries is over at Signal Health blogs.
February 15th, 2006A new MIT study suggests that Bush’s HSA plans will actually increase the number of uninsured, because businesses will respond by dropping coverage, and about 600,000 people won’t respond by buying coverage.
February 15th, 2006Norman Shumway, the first surgeon to do a heart transplant in the US died at 83 last week. He really was a pioneer and, from what I’ve heard from his colleagues that teach me, a really good and kind man, too. He will be missed.
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And so the morning routine begins, checking morning labs. I turn on the computer, login to the medical record system, and up pop a bunch of lab results for my favorite patient–he’d been transfered off my service to the surgeons, but I liked to keep an eye on him and his labs (I’m very protective), and I had forgotten how to turn off his lab notifications, anyway. I had just seen him the day before when I stopped by to say hello just briefly.
He has abnormal labs every day. A high blood sugar from his diabetes, a moderately low sodium, an elevated creatinine from his chronic kidney disease. I skim them again today. That’s weird. A critical result?
I double-click the chemistry panel. It’s probably just a high potassium before his dialysis.
CO2 9 L
RESULT RE-CHECKED AND REPORTED TO NURSE.
My heart skips a beat. What the hell? 9? That’s too low. Wait, CO2, that’s not pCO2. That’s bicarb. Bicarb is supposed to be 24. Oh shit. What the hell is going on?
I move the mouse over to the Notes tab of the system to get more information. I’m overwhelmed with the slew of the last 100 notes written on the patient. The most recent one is selected automatically.
Pupils fixed and unresponsive.
No! What the fuck. Wait, does that mean coma? What the hell does that mean? My eyes somehow skip ahead to the last line of the short note, as if they’ve already read the conclusion before my consciousness has.
Patient pronounced dead at 9:40pm.
I go back to read the lines again. Pupils unresponsive. No sign of breathing. No pulse or heart beat. This can’t be happening. Tears wet my eyes. I read through the last 5 notes. ICU transfer accept note. Pt found unresponsive, E-team notified. Patient intubated, blood pressure stable on pressors. Family arrived. Discussed patient’s status, and care was withdrawn. Pt extubated, put on comfort care.
I’m just stunned. That’s not how things go, I tell myself. You don’t go from smiling and with it and happy and you don’t just go see your favorite patient one day for 20 seconds, run off to do your work, and read that he’s dead the day you come back. You don’t die that way in a hospital. You die a long, protracted course in the ICU, where we throw everything but the kitchen sink at you. And you get better. And you get worse. And then you get better again, and then you get really sick. You don’t just fucking die like this.
I went up to the ICU to talk to the intern about what happened. Luckily I knew him, and luckily he’s a very outdoorsy, in touch with his feelings kind of guy, so I wouldn’t feel stupid to ask him what happened, and how the patient died, and if he was comfortable, and if his family got to see him before he passed, and what we tried to do to save him. He explained everything to me, and my mouth kind of did that little involuntary frown thing it always does when I feel just really sad and like I want to just lose it but I have to fight back the tears. He could tell I was upset. But it was okay to be upset.
So I walk back to the team room to finish my work on both my patients who are cranky and crotchety and tell one intern about it, and there’s not much reaction. The patient wasn’t his. I understand. I assume there will be a larger showing of grief with the other intern–the one seeing the patient with me. She finds out, and there’s a minute of a surprise, and sigh, and a discussion of what happened. But then it’s business as usual.
Both are incredibly caring people and will be wonderful, compassionate physicians, but more than anything I fear–no, I know–that this will become me. That I’ll have so many patients die on me that often their deaths will be only a minute of my time. Now maybe I’m wrong, maybe they grieve privately, on the inside, like I am. Or maybe not.
I guess I’m mainly so torn up about this patient because he was mine. And maybe it’s some sort of screwed up egotism. Or just that his death was so unexpected. Or that I spent so much time fighting for him, worrying about him, and trying to make sure he got his surgery and his studies as soon as possible. Or that I feel guilty for only giving him a casual Hello, how are you today as our final words. Maybe that’s all our relationship was to him to begin with.
But I think, most of all, I was upset was because he treated me like his doctor. I was the first one to greet him every morning. I was the one that helped him put in his hearing aids and change their batteries, getting his ear wax all over my hands time and time again. I was the one that always complimented him on the really great deep breaths he’d always take so I could listen to his lungs. And no matter how often I corrected him, he always called me Dr. Walker. He was the one that woke up one day, confused from getting too much medication, and didn’t understand he was in a hospital. He cursed at me, and I told him we were all here to help take care of him, and he groggily but immediately said he wanted a second opinion, as if I was his first.
After he was transfered over to the surgeons for his operation, I visited him every day, and he told me how much me missed my morning exam, and how much he loved hearing me encourage his deep breaths. He had gotten in the habit of mimicking me, without his hearing aids, to the point that he was practically yelling to the entire floor.
“Wonderful, just wonderful, Dr. Walker,” he used to say.
Item 1: Medicare is paying employers to maintain their retirement plan health care benefits, to the tune of $4 billion. These health benefits compete with Medicare Part D benefits.
Item 2: We already subsidize health care insurance, primarily through making business expenses for health insurance tax-deductible.
Item 3: Medicare isn’t allowed to negotiate on drug costs, although another federal agency, the VA, can. Medicare pharmaceuticals cost sometimes double what VA drugs cost.
Item 4: Our President’s plan to fix the health care system, Health Savings Accounts, is primarily targetted toward the middle- and upper-classes, those who already have health insurance. It also ignores the fact that approximately 80% of health care costs come from approximately 20% of patients (the really sick ones).
What’s next? The government subsidizing the drug companies for taking part in the Medicare D benefit?
Is it just me, or does it seem like our leaders are just setting up the government to fail?
A former dentist has been charged with stealing body parts from the dead and selling them for use in surgeries. He would take bone out, replace it with hardware PVC piping, and re-sew the bodies closed. Yuck.
February 24th, 2006Many pictures of the human body. Fantastic.
February 26th, 2006A really great Frontline on methamphetamine. And if you didn’t know this already, you can watch all the Frontlines of the past several years online, for free. +10 points to PBS!
February 26th, 2006Stuck between a rock and a hard place, a South Dakota blogger is describing how laypersons can perform abortions, anticipating the state’s ban that passed through the South Dakota senate. Excerpts include “Assuming you have no autoclave,” “Please be sure to familiarize yourself with the female reproductive system prior to performing any procedure such as this,” “Antibiotics can be purchased from Mexican pharmaceutical supply houses for less than $2 per course.” I worry greatly if this text has to be used.
February 26th, 2006I’m trying to get a(nother) site off the ground. If you’re a health care professional (physician, nurse, etc.) and work in a clinical setting, or a student, or just have a few extra moments, and you’d be willing to give me some feedback on a new website for clinical calculations, please contact me or leave a comment. Especially interested if you use a PDA! Thanks!
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Now would be a good time to wrap-up my long two months on my Internal Medicine clerkship, seeing as though I start Pediatrics tomorrow, which totally scares me because kids definitely don’t get my wry sense of humor and frequent pop culture references. In no particular, bullet order, because I’m just not in a paragraph writing mood tonight:
This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.
I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!
(To get rid of this thing, just wave your mouse over it. Ta da!
