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Commentology

Mitch came to the defense of Sanjay Gupta in the thread on Maggie Mahar’s post “Doubts About Gupta for Surgeon General.

“I guess I see this differently.  One, Gupta is one of the most respected surgeons in the country in his field.  Two, his work on TV makes him a natural communicator with the public, which we haven’t had for a very long time.  Three, using his TV work to condemn him pretty much says that anyone who’s been in TV should be automatically disqualified for government work.  Four, he talked about Anna Nicole Smith because that was his job; not everyone gets to pick and choose what they do or don’t want to do at work.  Five, Moore did fudge some of the facts, and if you don’t believe me, ask people in Canada, England, and Australia that live in larger communities how long it takes them to get major procedures unless they pay for it themselves.  And six, so he’s against medical marijuana; not every doctor agrees on every single thing.  What’s happened to qualifications as guideposts for whether someone is qualified for a position or not?  From where I sit, he’s imminently more qualified for the post of surgeon general than Leon Panetta is qualified to be the head of the CIA; true, it’s not a medical comparison, but it’s valid nonetheless.  Sounds like a lot of jealousy to me from no-name, if possibly qualified, physicians, who wish it were them than Dr. Gupta.”

Richard Reece MD had this response to Roger Collier’s Sunday morning post “The Siren Song of Public Programs …”

In their frenzy for public programs to expand cover to all, wonk enthusiasts removed from reality conveniently forget the key to making expansion work: physicians. Coverage without physician access is meaningless. And the only federal progam doctors hate more than Medicare is Medicaid. Both are bureaucratic landmines, and both pay considerally less than private coverage.

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Commentology

Bev MD emailed us in jest in response to "A Shakespearean Approach to Health care reform"           

"Whew, from your post's title I thought you were going to say, "First, let's kill all the doctors."

The thread on David Kibbe's post on "The Health IT chasm" continues to be an interesting discussion. Frog design's Stephen Sutton had this to say.

"As a designer active in developing healthcare solutions (hardware and software), I think it is worthwhile to consider the role of the design process used to develop medical IT, as a key contributor to its evident failure. Driven largely by a nightmarish regulatory environment, medical design projects tend to follow a dysfunctional process where much more attention is given to creating a paper trail than actually discovering and meeting the needs of end-users."

Scott had this comment in response to "The Importance of Being Charles Grassley"

"I like Grassley too, but why the worship of bipartisanship? There are only two structural reasons to seek a lot of Republican consensus: to get around/over a potential filibuster and to entrench the legislation so that a future change in government does not lead to its repeal.

David Kibbe had this to say in response to Bob Wachter's post on Medical Tourism's potential in tough economic times.

"I predict we'll also see US Medical Tourism, that is, states where care is much cheaper will attract patients to their facilities.  Not so exciting as India, perhaps, but Montana's not a bad place to go for your knee replacement, right?"

Grena Porto wrote in with additional background on Alan Rosenstein MD's post "Disruptive Physician Behavior: Fact versus Frenzy."

As a member of the Joint Commission's Sentinel Event Advisory Group and a champion of its efforts in this area, I would like to add a few comments to Alan Rosenstein's excellent posting:  1) the requirements in the JC's standards as well as the guidance in the alert released in July of 2008 clearly state that this applies to everyone, not just physicians.  2)  the work of Alan Rosenstein and ISMP clearly show that the behavior in question is not limited to physicians.  3)  although physicians are not the most frequent disrupters, their behavior tends to have the largest impact because of their relative power in the organization.

Alix Sabin offered this observation in response to Richard Reece's much-discussed "Confessions of a Cultural Anthropologist: The Real Cause of High Health Care Costs."

There is an inherent ticking time bomb in the health care industry’s business model. Health insurance is based on “young and healthies” buying coverage, but not needing care. It reminds me of the business of derivatives and sub-prime mortgages.

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Commentology

Alan Rosenstein MD’s post on "Disruptive Physician Behavior: Fact versus Frenzy" displeased several readers.  One fired back:

"How about disruptive administrators? Those who destroy
clinical departments thru incompetence, inexperience, and just plain
egotistical stupidity? What about arrogance, and general ahole-like
behavior? Got a regulation for that?"

JROSSI had this to say in response to David Reece’s Tuesday post "Confessions of a Cultural Anthropologist: The Real Reason for High Healthcare Costs"   

"Why is there a primary care shortage? I have been a family doctor for 19 years. Finally, the NEJM has touched the nub of the matter–I’ve been telling people this for years now.  It’s the new medical students who are increasingly bottom-line focused.  They were raised in a culture that is bottom-line oriented, and they’re not going to change. More money, less work (this is also a crucial factor that the editorial doesn’t discuss). Cultural, cultural to the core."

David Kibbe’s posting on the National Research Council’s much talked about report on "The Healthcare IT Chasm" drew this response from Peter Basch, MD.

"Kudos to the National Research Council for their comprehensive and
sober analysis of the state of health information technology as it
exists today, and for their thoughtful recommendations. These
recommendations reflect not just their research and editorial advice,
but the current conventional wisdom and implementation approach of
nearly all clinical informatics leaders.

A physician calling themselves J Bean had this to say in the same thread:

"I spend most of my evenings entering data into our new, multi-million dollar EMR and no longer have much free time except on Wednesdays.  I’ve stopped seeing patients one day per week so that I can have more time to wrestle with the computerized input of useless dreck …I was a systems and software engineer for a decade before I went to
medical school and I’m pretty under-impressed by what I’ve seen in the
field … It’s amateurish at best. It certainly doesn’t meet any kind of
standards for good user interface design. It does a remarkably poor job
of data aggregation. It doesn’t have a search function or even allow
easy access to older data, much less provide "decision support". It has
made my job harder rather than easier."

Commentology

Dr. Rodney Hornblake of Boston wrote us an email wondering if the Obama administration’s much- ballyhooed plans for Health IT investment may actually be slowing technology investment over the short term. 

"My partners and I have put on hold our planned implementation of e Clinical Works.  Scheduled for February the project is now on hold. The reason?  Obama’s emphasis on healthcare IT as an “economic stimulus”.  If we invest now we are likely to miss tax credits or other incentives."

Michael Millenson had this to say in response to David Kibbe’s posting this morning on last Friday’s Health IT report from the National Research Council of the National Academies. 

"The tunnel vision of the IT community is unintentionally shown by the comparison of the IT gap to the "quality chasm." That demonstrates a fundamental misunderstanding. The quality chasm is a gap between the care we have and the care we should have. Health IT, by contrast, is a critical tool in closing that gap — but it is only that, a tool. Just like telephones or, for that matter, file folders."

Rick was among the readers who commented on Dr. Val’s posting on Sanjay Gupta’s potential nomnination as Surgeon General …

"Dr. Gupta, while serving as a war correspondent for CNN in Iraq,
performed five emergency brain surgeries in the field. I don’t know if
that counts for military experience, but anyone at the Pentagon who
overlooks it ought to be reminded — though I expect Dr. Gupta would be
too polite to do so.

Frankly, it sounds like Dr. Jones’ anonymous source has a case of
the sour grapes, resentful at getting passed over by someone with more
star power, or at least, is close to people who are."

Meanwhile, skeptic writes:

"The director of public health for Los Angeles County (Jonathan Fielding
MD) or his New York City counterpart would be far better candidates for
Surgeon General. Both have experience running large organizations and
noteworthy accomplishments, along with excellent PR skills."

Commentology

Longtime THCB reader Barry Carol writes in on Matthew’s "Shocker …"

"Most hospital CEO’s, especially those who oversee academic medical centers, would probably tell you that their profit margins are quite low and that they could not make ends meet or continue to provide the quality of care they do now if they had to accept Medicare rates from all comers, even with no uncompensated care …"

David Kibbe continued the ongoing dialogue on the thread on the "Rebooting Health IT" series he is co-authoring with Brian Klepper.  

"Having thoughtful physicians like yourself enter the debate and
discussion is one of the primary reasons that Brian Klepper and I are
doing these blogs on re-thinking health IT! Thanks for your input,
which I think is brilliant … Let’s not forget the story of John Snow and the removal of the Broad
Street pump handle, during the deadly cholera outbreak in London in
1854. While all the experts were debating the causes of the infection
and what to do about it, Dr. Snow had the simplest and most direct
answer of all: remove access to the offending source of the calamity."

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Commentology

Rick Peters, commenting on John Halamka’s post, the "Broken Window Effect"

"Speaking of downtime – have you ever determined why your organization,
mine, and virtually everyone in health care does routine scheduled
system downtimes on Saturday nights? I understand the theory that it
gives you Sunday to recover, but there isn’t an ER in the country that
isn’t busiest Friday night, Saturday night, Sunday late
afternoon/evening, and Monday night (Tuesday if it’s a three day
weekend). More admissions to our institutions occur at those busy ER
times than at any other time. I would think that physicians in IT
organizations could change this – do routine downtime on Wednesday
night, and in reality do it Thursday morning between 3AM and 5AM –
that’s when things are quiet."

Maggie Mahar has this to say in the thread on Matthew’s "Critical of Critical"" post …

"As for group practice vs. solo practice–solo practice is becoming economically unaffordable. More and more younger doctors recognize this, and would prefer to work in a very large group, on salary. The Dartmouth reserach also confirms that the most efficient outcomes (high quality at a lower price) come in multi-specialty centers where docs are on salary."

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