Rant: How is American healthcare broken, let me count the ways.

Watching the State of the Union address got me thinking about all the ways the healthcare system in the US is, lets face it, FUBAR. This is from the perspective of a new physician in the field. The perspective of a new physician provides a fresh look at what is wrong with the system, though it also means my list is going to be shorter than that of a physician who has practiced for years. If you want to hear about what Scott Weingart, emergency physician/intensivist and founder of the blog EMcrit, thinks is the most pressing problem to be fixed in medicine then listen here:

http://emcrit.org/rants/risk-in-em/

I'll start on the same theme as Dr. Weingart.

#1. Medical malpractice and tort reform.  What is risk, and whose risk are we talking about?

The current state of the malpractice system in the US is a sorry state of affairs that any self respecting attorney should be ashamed of. Going into all the ways the tort system negatively affects the healthcare system, and thus hinders the ability of the system to provide quality care to patients, will have to wait for another blog post. 

The system is about money, not about malpractice. Lawyers know they can make money and have no risk by filing frivolous suits. In fact, its gotten to the point where hospital defense lawyers know exactly how much money it takes to go to court; if a claimant asks for less than that the hospital (and/or physician) coughs up the money. No questions asked. Cases that do go to trial are the ones where the claimant demands more money. Hospitals will always try to settle unless they are certain they can prevail in court, so the trials we do see are the ones that are often the most ridiculous. It doesn't stop there though, studies of malpractice suits have shown that who prevails in a suit and how much money is awarded is not correlated with the merits of a case. Let me say that another way. It does matter one bit who is right or wrong in a trial to determine who receives judgement. So what matters? How sorry the jury feels for the claimant. And its not only the hospitals and physicians that pay, its all consumers of healthcare. Lets take an example of a recent tort case in Florida: a patient arrived at a hospital after being involved in a serious motor vehicle accident. The patient was in shock and dying on the table. The physician who took care of her was renowned in Florida for being one of the most progressive and aggressive trauma specialists in the state. He had saved the lives of thousands of trauma victims in his career. So what did he do that was so wrong in this case that resulted in him and the hospital getting sued for 20 million dollars, him getting a permanent black mark on his record, and subsequently leaving the state depriving the people of Florida of the services of this amazing physician? He did his job. He saved the woman's life. There is no debate that if he hadn't tried as hard as he did, or if he hadn't been as good of a physician, that he never would have ended up in court. In the end, the woman required massive transfusions and aggressive shock treatment to survive. Do to the amount of blood she lost she was unable to pump blood to her extremities and subsequently lost both of her feet and her arms below the elbows. But she lived. And since she, and her lawyer, could not sue God, they did the next best thing.

Okay, so its easy to see how this drives up costs for all of us and creates a harsh working environment for physicians. Its also easy to understand why physicians practice what is called "defensive medicine", the practice of ordering test after test to attempt to eliminate risk of missing a diagnosis, often without regard to costs or to the risks associated with the diagnostic procedure themselves (e.g. its better to CT scan a baby to make sure you don't miss that .001% chance of a head bleed that is clinically occult than to worry about the 2% chance of future cancer associated with scanning a young patient). What isn't easy to see is how the system hamstrings the advancement of clinical research in the United States. In fact, very little cutting edge clinical research is currently done in the US. Most of it is done in Europe where researchers can examine best practices without having to worry about getting sued for trying to do what is best for their patients. Very little outcome data is collect here, and as a result we have little understanding of which of our daily clinical practices are any better than the others. How are we to cut costs, how are we to decide which practices help our patients and which hurt, when we can't even do the trials because we are so afraid of medical-legal risk? And don't get me started on how phony malpractice claims effect malpractice insurance for OB/Gyn and emergency physicians. Suffice to say, the fact that you can not find an OB/Gyn to deliver a high risk infant in many southern states speaks for itself. If we create an environment so hostile that physicians go elsewhere, then who will remain to care for the sick? As many southern states are finding out, no one will. 

I really must agree with Dr. Weingart here. Mistakes and malpractice are not the same thing. One is preventable, the other is not. One should be punished, the other should be minimized. If patients, and malpractice lawyers, truly want to decrease malpractice and increase "best practice" of medicine then liability as we think of it today should not exist. 

#2. Privately funded medical education. Almost all civilized countries have publicly funded medical education systems, we're the exception. The result? Massive debt my medical students and young physicians creates an environment where most physicians don't go into the black until middle age. Lots of problems associated with that, from burn out to billing practices to salary expectations.  

#3. Our current method of residency training. Its long, its inefficient. It treats young physicians as slave labor, forcing them to work long hours (longer than is safe) for very little pay. Some of the most highly skilled and educated surgeons in the world could make more money working at McDonalds. Get rid of the abusive training system and you'll have a happier and safer workforce. 

#4. Failure to standardize education. 100 years ago we saw the problem with having a lack of standardized scopes of practice. Now we have a plethora of grey areas where non physicians providers practice. The results of this haphazard system are just as bad for our patients as it was 100 years ago. Whats the kicker? Originally begun to save money, studies show that non physician providers actually cost the system more. Go figure. 

#5. Middlemen. They are everywhere. Insurance company overheads, government inefficiency. Its all waste that does nothing to better healthcare yet sucks dollars out of the system and contributes to the massive healthcare debt in this country. 

#6. Medicare. Ask anyone in medicine and they'll tell you its broken. Its not even a debate. Yet we're all so afraid to do anything about it. Medicare (and even worse, Medicaid) pays less than costs for most procedures, so the loss has to be made up by overcharging paying patients (e.g. non Medicare patients). Private insurance companies wonder why they should pay for procedures when the government doesn't; good question. Now, lots of them aren't paying either. The result, some physicians close their practice, some charge their insured patients higher and higher rates, and others simply opt out of the Medicare system all together and take only privately insured and cash patients. 

A recent publication in a prominent medical journal illustrates how some physicians are finding the only way to practice medicine the way they want is to refuse Medicare/Medicaid all together. A California physician found that when he opted out of Medicare/Medicaid he no longer needed to employ 3 medical coders and his overhead costs were reduced by 200%. By taking only privately insured and cash patients he was able to double his revenue stream. He posts the costs of every test and procedure in his office waiting lounge so patients know exactly how much everything costs. This helps them decide which elective tests are really needed. Patient satisfaction also soared, he was able to spend an hour with each patient instead of the 10 minutes he was forced to see patients with under Medicare. Word got out about his clinic and he started to draw patients who would pay cash rather than be forced to endure another 10 minute Medicare funded evaluation. He opened up his Friday's to patient's as a free clinic so he could see patients who couldn't afford him or didn't have insurance. The end result was better job satisfaction, better physician income, lower patient costs, and much higher levels of patient satisfaction. All without Medicare. 

#7. Direct to consumer advertising by pharmaceutical companies. Not only does 20% of the costs of your medications go allowing pharma to place advertisements for you to watch during Oprah commercials, but the truth about a lot of on patent medications is that most patients don't need them. Yes, thats right, the inexpensive generic medications work just as well for most patients. Try to tell that to the patient who comes into the office demanding the newest drug they just saw on TV and an argument is sure to ensue. Most physicians just give up and write the prescriptions their patients ask for, even if they'd be served just as well by a generic. Not only is it not good for patients, but they pay extra for the privilege. Only in America...

#8. "Empowered" patients and an emphasis on autonomy over physician judgement and beneficence. More on this later, but suffice to say many patients make bad choices and their physicians fail to dissuade them otherwise because our society is afraid of physicians making choices for them. Medicine, like the other profession (law), requires years and years of study to fully understand, the very reason we seek out medical advice from physicians is because they have special knowledge and we want their opinions.

In a similar vein, I can't even recall the number of times family members have requested physicians take extraordinary measures for their parents (child, spouse, whatever). No one wants to think that they didn't do everything possible, but spending large amounts of money, prolonging pain and suffering, and in some cases causing harm with inappropriate testing (*cough* please, please just scan my child*cough*please give my kid an antibiotic for this viral infections*cough*please my 91 year old mother with 13 medical comorbidities will get better after this 15th hospitalization*cough*) will only increase how much of our GDP we spend on healthcare and won't get us any better results. Physicians know the down side of inappropriate tests, medications, and procedures; they need to grow some backbone and stand up to demanding patients who ask for inappropriate care. 

#9. Lack of individual responsibility. A large proportion of medical expenses are spent on treating illnesses associated with lifestyle choices of Americans. Obesity, sloth, and the usual "vices" take a toll on the human body; the medical system expends vast amounts of resources trying to fix years of bad lifestyle choices when they could easily be prevented from occurring in the first place. In spite of this our healthcare system manages to keep us alive longer and longer, at greater and greater cost.

#10. Fragmented care of uneven quality. American healthcare was once aptly described as pockets of absolute excellence surrounded by vast areas of suboptimal care. We need to implement best practices in a standardized system everywhere in the US, not just at big academic institutions or cutting edge private clinics. We need to get rid of the barriers (financial, medical-legal, etc.) that keep physicians from practicing in less desirable parts of the nation and get rid of incentives that encourage doing more for patients over doing what is best for our patients. 

I'm ending this artificially short list here, it could go on and on. But lets be honest, its already depressing enough at #10, and who wants to keep reading?  

Tactical Emergency Medical Services-Docs with glocks?

The concept of physicians and paramedics working with tactical teams is relatively new. Tactical teams, known variously as special weapons and tactics (SWAT), special response units, rapid response units, or hostage rescue teams, were first established in 1968 in Los Angeles. SWAT teams often utilize paramilitary tactics and respond to a variety of emergencies that ordinary police units are ill equipped to deal with. The possibility of injury to team members, hostages, and suspects and the need for integrated operational security led to the incorporation of medical elements within these teams. Tactical emergency medical services/support (TEMS) has now become standard (and in states like California, codified) and the role of the physician has evolved beyond simple direct support of a tactical team. The need for such medical support has been clearly illustrated by incidents where their presence effected a positive outcome as well as when their absence has led to preventable poor outcomes: the 2002 Moscow theater siege that resulted in 169 fatalities (139 hostages) and hundreds more hospitalized or the 1993 breach of operational security at the Branch Davidian complex in Waco Texas that led to the deaths of 82 Davidians and 4 ATF agents.  

TEMS providers are often employed either part time or on a volunteer basis as the frequency of SWAT call outs combined with the necessity to maintain their medical acumen makes full time activity impractical. Training for TEMS is also variable, most departments require a minimum of attendance at a tactical EMS school such as CONTOMS (Counter Narcotics and Terrorism Operational Medical Support) school or the former HK school (now known as the International School of Tactical Medicine.
https://www.trueresearch.org/contoms/
http://www.tacticalmedicine.com/
These 1-2 week courses familiarize medics with tactical operations and their role in a tactical team. They typically also provide familiarization with the common weapons used by SWAT teams: Glock pistols, MP5 submachinguns, M-4/AR-15 carbines, and tactical shotguns. The level of weapons training varies from being able to clear and safe these weapons to full qualification. Other training specific to TEMS includes tactical team movement, armored operations, helicopter operations, night operations, chemical agent training, weapons retention and combatives, patient packaging and movement, and emergency medical procedures in zero visibility environments.  Most of this training focuses on preparing the provider to work in the extremely austere tactical environment and follows the treatment guidelines outlined in the military combat casualty care (TCCC) curriculum.  Very active departments commonly choose to send their medical providers to a full SWAT school so that their TEMS officers are cross-trained in all facets of tactical operations. 


The role of the medical provider varies by locality. Some TEMS providers are sworn, armed, fully integrated members of a tactical team. These providers are able to provide for their own security during entry scenarios and are able to tactically engage suspects if the need arises. Other providers are posted at the tactical perimeter ready to make entry as soon as the need arises. While the former is preferable, the latter may be necessary due to training limitations or political considerations. Large units often have a medical provider that makes entry with the team while another provider, acting as medical commander, remains in the command post to advise the SWAT commander. Whatever the model, attending standardized training and regular training with the SWAT team is an absolute necessity if the medical provider is going to become an active and trusted team member. At the physician level the role of tactical medical support has expanded to include medical threat assessment, large event medicine, VIP/protective and government security services, and press relations.   


The tactical environment has many unique challenges that is beyond the training and capabilities of pre-hospital medical providers. Medical support for tactical operations is now seen as an essential component for any tactical team. Physician medical directors represent the most specialized application of medical care, and are ideally positioned to act as facilitators of tactical-civilian integration and advocates of standardized training for TEMS providers. With the expanding role of physicians in operational and tactical settings its clear that the future will hold many exciting possibilities that push the boundaries of "traditional" emergency medicine and may one day be considered an EM sub-specialty in its own right. 

Direct physician medical director involvement in pre-hospital care.

Pre-hospital care in the United States is provided by emergency medical technicians who work under supervision of a physician medical director. In Europe, pre-hospital care is provided by medical technicians who work side by side with physicians. In some parts of the US physicians (usually EMS fellows) have response vehicles and will respond to certain types of incident, like multiple vehicle motor vehicle accidents, mass casualty events, witnessed cardiac arrest, prolonged extrications, fires, tactical medical scenarios, large events, and certain pediatric calls.  In France and Germany they claim significantly better outcomes than here in the states by having physicians directly involved in pre-hospital care of trauma, cardiac arrest, infarction, and stroke patients.

To my surprise, I've found that many States-side medical agencies do not have medical directors trained in emergency medicine, and fewer yet have ones who are fellowship trained in EMS. Beyond this superficial observation there is a paucity of research into how involved medical directors are. Surveys seem to indicate that some agencies have medical direction in name only, at times by physicians with no familiarity with emergency medicine or EMS (e.g. radiologists). Most medical directors that are involved usually spend their time in retrospective quality assurance and paramedic education, but very few undertook on scene quality assurance or responded to calls that would have benefited for physician involvement.  Many medical directors reported working part time or on a volunteer basis, and as such were not always available for online medical direction when needed. The challenges add up further when you include medical direction of fire department based medical services and the issues relating to medical direction of technicians whose primary role is to fight fires rather than provide medical care.

Pre-hospital medicine has developed tremendously in the last 25 years, however it seems clear that certain areas are still in need of substantial improvement. Legislative efforts to standardize requirements for medical directors (minimum EM residency trained) and financial incentives for physician involvement would go a long ways towards improving the medical direction and oversight component of EMS systems.

Some links with further reading, if you're interested:
http://www.ncbi.nlm.nih.gov/pubmed/8370290
http://www.northjersey.com/news/70437017.html
http://www.ncbi.nlm.nih.gov/pubmed/19780921
http://www.shepscenter.unc.edu/rural/pubs/report/FR93.pdf
http://www.ncbi.nlm.nih.gov/pubmed/11727688
http://www.sponsorhospital.org/aspxpages/SharpTeam.aspx

Mayo Foundation for Medical Education and Research v. United States

Congratulations to the Supreme Court for making a decision that is probably firmly based in legal precident yet completely fails to take into account reality.

Look here for the full text: http://www.scotusblog.com/case-files/cases/mayo-foundation-for-medical-education-and-research-v-united-states/

 Resident physicians have a dual role that is mostly work but also contains an extensive educational component, especially during the first year. They are no longer doctors in training, but rather doctors who are pursuing board certification. They are licensed physicians that work on average 80-100 hours a week, attend scheduled educational sessions (usually daily over the noon hour), and occasionally provide indepedant care at facilities other than their primary employment (moonlighting).  Formerly classified as not quite student and not quite employee, this vagueness meant that institutions and residents did not have pay into the social security system prior to 2005.  This is similar to postdoctoral research fellows.  Like residents instead of pay they receive "stipends" that FICA is not withheld from.

Now that residents are "employees", do they have employee rights, the same as other employees in America? The National Labor Relations Board already ruled almost a decade ago that residents could unionize, but so far this phenomena has been limited to a few locations.  As employees, will residents have the right to collectively bargain? Will they be able to renegotiate the pathetic "salaries" that haven't changed in two decades? What about work strikes or slowdowns? What about continuing to work (so that patient care is not affected) but refusing to bill for their work until demands are met? Heck, what about overtime pay?

Perhaps this decision will be the beginning of a change the in power balance between institutions and residents. While certainly not their intention, the Supreme Court might have changed the cheap labor racket that hospitals have been taking advantage of for decades.    

Medical Grand Rounds-new duty hour rules for internal medicine residents

Grand rounds today discussed the new institute of medicine recommendations for resident work hours. In 2003 the IOM placed limits on how much resident physicians can work, 80 hours a week, and only 30 hours in a row without a break. From what I've seen this has made residents' lives a little better, but they still do the same amount of work, the just do the paperwork (electronic) from home now instead of at the hospital so the hours don't count. They even showed a study that showed that almost all residents reported checking labs, ordering tests, and writing notes from home during their off time, even when post call.

Since 2003 there have been a lot of studies to see how this changed practice, none of which were controlled trials. Most of these studies show that: first, resident training suffers. Duh. Less hours means physicians who are not as well trained as they were in the past. Most studies indicate better safety, at least in the near term. Nothing looks at how the detriment to training effects mortality. Most studies indicate less burnout. Thats good at least. Now the Institute of Medicine wants more limitations. The problem is, the work of medicine isn't decreasing, so who will take care of the patients. There are three solutions I heard offered today. First, consulting (attending) physicians will pick up some of the workload. Sure...after working 70 hours a week they'll want to pick up patients for residents. And of course, they'd do it for free, right? Second, physician extenders. Nurse Practitioners and Physician Assistants, nurses or college grads who get 2 years of advanced nursing training, could pick up some of the more routine procedures and clerical work for residents. Problem is, they already do this, they work banker hours, and they aren't any more eager than consulting physicians to take on more work for free.  More worrisome, there are numerous reports of physician extenders working relatively unsupervised or stepping outside their scope of practice, a disaster in the waiting for patient safety. Lastly (and most interestingly) is to have college students work as medical assistants. Most of these are premedical students eager to get any clinical exposure they can, like being a scribe or a nurse assistant. Best of all, they work for peanuts. Sounds like we've found a winner!

So back to the residents. What is the solution? How do we keep the experience the same, a balance between work and education, without increasing the length of medicine residencies? Being that our medical education system is NOT publicly funded, its not likely that the debt ridden and underpaid residents are likely to agree to an additional year of indentured servitude. I've yet to see how the Institute of Medicine proposes to decrease hours, keep the amount of work done the same, and maintain the quality of the medical residency experience.