Medicare Micromanaging

The latest kerfuffle drawn from the double-ream of paper that is the new Congressional health care reform bill stems from the provision about allowing payment for a discussion of end-of-life care every five years. (What if the patient develops a new life-threatening condition four and a half years after the last discussion? Sorry, dude. You should have either thought of that four and a half years ago, or waited six more months to get sick.) Several other bloggers have already weighed in, mostly in an effort to debunk the deceptive misreading by right wingnuts claiming that the provision calls for euthanasia (which it of course does not).

The fact of the matter is that the provision is unnecessary, and is just another example of governmental attempts to micromanage medical care. This is an assertion I can actually prove.

In the first place, Medicare already pays for counseling. As long as more than half the face-to-face time of the visit consists of "counseling and/or care coordination," Medicare pays the visit based on the elapsed time of the encounter. Please note that there are no limitations on the topics discussed for the visit to qualify for payment. I can and do frequently bring elderly patients into the office and spend the entire visit discussing issues such as end of life care. I document and bill it accordingly, and no one blinks an eye. Nor should they; this is a completely legitimate medical encounter. It doesn't matter whether it happens once a year, once every two months or once every five years; whatever is appropriate for a particular patient is what I do.

That is why this new provision adds nothing of value to Medicare patients. On the surface it may sound like a good idea, but I have an example of something else that started out making sense that, once the government got ahold of it, perverted it completely out of any semblance of usefulness. I am speaking of the "Welcome to Medicare" physical.

It turns out that the way the original legislation was written, Medicare is legally forbidden to pay for preventive care. Various specific work-arounds have been legislated over the years to allow payment for specific items such as flu shots and pneumococcal vaccination, and a few years ago Congress decided to explicitly include a single preventive care service. Because this service was only eligible for payment during a patient's first six months (more recently extended to twelve months) on Medicare, it became known as the "Welcome to Medicare" physical.

"Wonderful!" I thought when I first heard about it. Finally, Medicare would pay for at least one preventive visit actually so labeled, as opposed to a more extended evaluation once a year that I usually do for my patients with multiple problems that I think of as a "physical" in my head, but never dare write down on paper. Ah, but then the devilish details came out.

Apparently Medicare didn't trust my version of what constitutes an appropriate preventive care visit. Instead, they promulgated detailed regulations about what the encounter had to include:

• Height
• Weight
• Blood pressure
• Visual acuity
• Electrocardiogram
• Depression screening
• Functional ability/safety screen
• Counseling and referral [note: NOT performance] of other preventive services, including:
  • vaccines
  • mammogram
  • pap and pelvic exams
  • prostate cancer screening
  • colorectal cancer screening
  • diabetes screening tests (and self-management training for patients who already have it)
  • medical nutritional therapy for diabetes or renal disease
  • cardiovascular screening blood tests (lipids)
    
  • bone mass measurements
  • glaucoma screening
  • abdominal aortic aneurysm screening sonogram

Note that these are minimums. I can do anything else I feel is appropriate for a preventive care visit above and beyond these things, though I don't get paid anything extra. The result is predictable: the "Medicare Initial Preventive Physical Examination Encounter" has become more trouble than it's worth. I tried it a few times. Basically, it turns into a generalized risk assessment for things like falls and depression, along with a most cursory exam. Frankly, once I'd finished covering all the "required" bullet points, there wasn't really any time left for my version of a physical (including an actual history, where one listens to the patient, as opposed to ticking off yes/no boxes to satisfy Medicare's documentation guidelines for the MIPPEE). It doesn't even pay all that well. Nowadays I'll do one if a patient requests it, but it's not something I'm pushing, as it doesn't add any value to the medical care I provide.

My fear is that CMS will promulgate a specific new code that must be used to bill these quinquennial visits for discussion of end-of-life issues, and that certain specific topics must be discussed (and documented) in order for the visit to be paid. And unless that particular code pays significantly more than a corresponding evaluation/management (regular office visit) code, I'm not going to bother. Oh, I'll continue to have discussions with my patients about end of life care and other issues on a regular basis, but all the sturm und drang about this provision will have been nothing but a giant waste of neurotransmitters and electrons.

Making Money in Primary Care

Imagine my excitement when I read the following headline of a post by Shadowfax:

How to Make Money in Primary Care

You can bet that caught my attention. What wonderful secret had the great and mighty Shadowfax unearthed about the economics of primary care? Enlighten us, oh wise one.

Turns out that the Cleveland Clinic pays primary care really well. How? Like many other large multispecialty groups, primary care is considered a loss leader. That is, primary care physicians get paid more than they generate for the practice directly, in recognition of the income produced by their referrals to the group's specialists and ancillaries.

Yawn. Old news.

So what if someone either doesn't want to work in a large group practice, or if one wishes to live in an area devoid of such an organization? How might this work?

Say specialists agree to supplement the income of referring primaries from their inflated receipts of the RBRVS, in recognition and appreciation for the work sent to them. Wait, I think there might be a name for this kind of arrangement. Oh yeah; it's called a "kickback." In fact, I'm pretty sure it's illegal (for doctors, that is. It's standard procedure for lawyers.)

How about ancillary facilities like labs and freestanding radiology centers helping to compensate primary care docs for all the lucrative business they refer? Wait; wasn't there a guy in Washington who didn't like the sound of that? Pete Somebody? Didn't they promulgate not one (I), not two (II), but THREE (Stark III) sets of regulations that basically prohibit that kind of monetary transfer?

Yes. Why yes, they did.

So with apologies to Shadowfax, it turns out that the only way to make money in primary care with the current payment structure is to cast my lot in with generous, far-sighted specialists who recognize my worth. Too bad no one else does.

Over-Scheduled Children

Much has been made of children with so many scheduled activities that they spend their entire day running from one to the next, with no time left to do anything else. Playing; daydreaming; just being; all are vitally important for children to develop into complete people that this ubiquitous over-scheduling runs the risk of hindering our kids' lives rather than enhancing them.

I get a call from a patient who, last time I heard from her, was pregnant:

She: Hi, I'd like to schedule an appointment for a newborn checkup.

Me: Ooh! You had the baby. How was it? What did he weigh? (etc. ad cuteness) (because of course why would she be calling for a newborn appointment if she hadn't had the baby yet?)

She: Um, actually, the C-section is scheduled for next week. I just wanted to get the appointment made ahead of time.

Now that's what I call organized. She, on the other hand, had this comment:

"Talk about over-scheduling our children."

On Tough Decisions

The topic of tough decisions has been raised by Buckeye Surgeon, who handled a difficult situation with care and finesse, and butchered (as usual) in response by Happy the Hospitalist.

After careful consideration, consulting with the patient, family, and attending physician, Buckeye proceeded to implant a port into a 92-year-old woman for chemotherapy to treat recurrent breast cancer.

After a superficial reading of the post and the relating of a completely non-analogous anecdote, Happy states that "being 92 and functional is not a good enough reason to abuse patients in their last few months of life..."

I shall take him up on his invitation and call him an ignorant, cold-hearted jerk.

In the first place, chemotherapy administered to a competent, conscious, cognitively intact 92-year-old patient after careful consideration and extensive patient education and discussion about side effects and outcomes does not constitute "abuse." Working up a 90-year-old patient with metastatic pancreatic cancer and recommending aggressive therapy, on the other hand, does.

The point I have made before (here) is that if we somehow managed to stop wasting time and money on futile care, aggressive end-of-life interventions, and expensive high-tech procedures never proven more effective than lower-cost treatments to patients of all ages, there would be plenty of resources available to provide appropriate comfort care and medical treatment to the vigorous elderly.

Buckeye's vigorous 92-year-old is the exception. Exceptional cases make bad policy. For every functional nonogenarian, there are dozens of nursing home denizens whose bodies are forcefully being kept alive even though their souls have long since departed. If we refrained from spending fortunes on ICU care every time they try to die become septic and just let nature take its merciful course, there would be no need to argue about taking care of spunky old 92-year-old ladies who still have all their marbles.

The Early Bird Gets the Dinosaur

Even though the official release date for DECLARATIONS OF A DINOSAUR; 10 LAWS I'VE LEARNED AS A FAMILY DOCTOR isn't until August 4th, I have it on good authority that folks who have pre-ordered the book on Amazon are receiving it early; as in now. Here is my evidence:

Thanks to Book Fan #1 for the picture. As it happens, she isn't actually the first to receive it, just the first to send me a picture (ie, Don't get your panties in a knot, NK.)

I Call Bullshit

Other bloggers have brought this to my attention, but I must join in as well.

Barack Obama, 7/22/09, 47 minutes into a nationally televised press conference (emphasis mine):

We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference. So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care.

I call bullshit, Mr. President. Bullshit, plain and simple.

How dare you claim that my medical decisions are based primarily on financial considerations? (In fact, when I do take finances into account, it's usually those of my patients without insurance or otherwise limited resources.) How dare you!! I work my ass off day in and day out making medical decisions based on the best scientific evidence available -- while earning only one tenth of what you do, I should add -- and you have the unmitigated gall to claim that I'm only in it for the money.

Where the hell did that come from? Please tell me you don't really believe that's how doctors make medical decisions? What were you thinking? You have a reputation for understanding complex and highly nuanced situations like the Middle East. I was under the impression that you understood that health care in America deserves similarly careful consideration. Please tell me your above remarks were off the cuff, that you spoke without thinking, and that they do not really reflect your opinion of American doctors.

Echoing Dr. Wes, you owe an apology to the doctors of America.

Edited to add this from the comments, courtesy of Rogue Medic:

Money is just one variable in a complex system. Suggesting that doctors are incapable of making decisions, without being forced by money, is disingenuous, sophomoric, and insulting. Insulting to everyone, not just insulting to doctors. For this blatant exibition of prejudice, President Obama owes an apology to all Americans and to doctors in particular.

(Read his whole comment.)

Just for Fun - Another Time Waster

In honor of the arrival yesterday of my parents' 13th grandchild, here's a fun little interactive graph showing the frequency distribution of baby names over the last century:

Baby Name Wizard

Just for the record, the name Henry was the 8th most frequent name given to boys in the 1880's, steadily decreased to the 120th by the 1970's, with a gradual climb back upward, reaching the 78th in 2008.

Cole, on the other hand, doesn't even appear in the top 1000 (tracked by the graph) until the 1940's, and then takes a very sharp upturn in the 1980's, reaching a peak at the 70th most popular name in 2003.

Congratulations, M & P. (Everyone else, don't blame me for all the time wasted at work.)

What is it with Food and the Pelvic Floor?

Once upon a time, a doctor named Arnold Kegel figured out a way to measure the vaginal pressure exerted by voluntarily contracting the muscles of the pelvic floor. He also advocated regularly exercising these muscles, as strengthening them presumably helps relieve symptoms of genital prolapse and incontinence. These exercises are now epononymously known as Kegel exercises, or just "Kegels."

Why is this term so hard to remember? And why do people always come up with various food-related terms when they're trying to think of it?

The first time was pretty funny:

The incontinence is getting worse. Those Jewish food exercises aren't helping at all.

Of course she was talking about Kugel.

But it happened again yesterday! A new patient discussing a urinary problem:

I've tried those exercises. What are they called...kelloggs? Keggers?

Now we're up to noodle casserole, cereal and beer. What next??!?

50-Year-Old White Female Blogger

Maurice over at the Bioethics Discussion Blog posted a recent take on an old issue: how much information to try and squeeze into that all-important "first line" of the history and physical. Should medical students be taught to include or exclude medically "extraneous" data like race, ethnicity, marital status, etc. in their case presentations? Like this:

45-year-old black female homemaker...
57-year-old married white male machinist...
74-year-old left-handed retired Asian math professor...

The argument is that aside from age and gender, all the other information about ethnicity, marital status and the like is not medically necessary. This is true. The big arguments, of course, center around race, with the presumption that certain diseases have certain racial predilections. This, of course, is also true and not true, in that race is recognized as more of a cultural construct and has much less biological significance than previously recognized, although certain conditions do indeed occur with greater frequency in persons of various genetic backgrounds.

Some other pieces of information are specialty-specific. Neurologists usually include handedness in their opening statement, because it is often germane to the conditions they encounter. Not always, of course; who cares what hand a migraineur writes with. Still, it is part of their schtick. It is also logical for Occupational Medicine notes to make prominent mention of the patient's occupation. So there are isolated instances where seemingly extraneous information becomes relevant.

The rest of the discussion centers on the perils of physicians pre-judging their patients, falling into stereotypical thinking on the basis of the descriptors included in the H & P's opening statement. I believe this fear is overblown. Hopefully doctors refrain from jumping to any prejudicial conclusions solely on the basis of the first words of a case presentation.

That said, I think the entire argument is moot.

The unspoken assumption when talking about teaching medical students "how to do a history and physical" is that there is a "right" way to do one, including a "correct" way to present one's findings to others. It is true that there is indeed a standardized format of sorts for an H&P which ought to be taught to medical students. It usually contains the following components:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
• Family History (FH)
• Social History (SH)
• Review of Systems (ROS)
• Exam
• Lab, Imaging and other studies
• Formulation or Assessment (diagnosis), and
  
• Plan
  

The problem is that in real life (as students will learn their first day of their clinical studies) this format is extraordinarily context-dependent. Different sections of the history take on different significances depending on the patient's circumstances and the physician's specialty. Past medical history is usually nonexistent in infancy (aside from information about the pregnancy, labor, delivery and nursery course), and family history is immaterial after the age of 80. In essence, students have to learn a whole new H&P format with each rotation.

This is not wrong. One thing that bothered me in medical school was classmates who claimed that they had been taught to do the H&P a certain way, and by Gd that's the way they were going to do it. Um, no; when you're doing Obstetrics, it's not that important to determine what the patient's grandfather died from and whether or not she ever had her tonsils out. (Just try asking all your Review of Systems questions to someone in active labor and see how far you get.) The idea that the H&P for the initial presentation of an adult patient with a medical (as opposed to surgical) problem, as taught in medical school, is the only "right" way to do an H&P is inflexible and impractical. Similarly, the idea that "presenting the patient" is always done exactly the same, regardless of whom you are presenting the patient to (and the reason for the presentation) is nonsense.

Think of an H&P like a painting. There are many different kinds of paintings: still life, portrait, landscape, miniature, abstract, and so on. There are the basic artistic concepts of design, line, light, color, layout, but different kinds of paintings require emphasis on different principles. If you imagine all students beginning with an oil painting of a still life of a vase of flowers, how silly is it to think of them complaining that a landscape isn't a "real" painting. In our case, that internal medicine patient presenting for the first time with a new problem (as opposed to a patient in the ER, or a patient needing a pre-surgical evaluation, or a newborn, etc.) is the equivalent of the floral still life. Learning to recognize when that form is appropriate is half the battle.

In terms of presenting the patient, again, context reigns supreme. The formal version discussed by Maurice is designed for the presentation of a new patient to clinicians who do not already know the diagnosis. ie, a clinical puzzle, as seen in the New England Journal of Medicine and elsewhere. As third year medical students will quickly learn, that won't get you very far on morning rounds. "Hemicolectomy, post-op day three, afebrile, passing gas" is all they want to hear on surgery. "Mulitip at six centimeters an hour ago, comfortable with epidural" will do on Obstetrics. You get the idea.

After all that, though, in answer to Maurice's question, I'm going to come down on the side of more information in the opening statement rather than less. I'd love to hear something like, "58-year-old married female secretary who just dropped her last child off at college and started art lessons last week..." and here's why. It has to do with this quote from Sir William Osler:

"The good physician treats the disease; the great physician treats the patient who has the disease."

The more I know about the patient who has the disease, the better job I will be able to do caring for that patient. How better to get to know the patient than to describe him or her as fully as possible right from the start of the encounter. For those who worry about stereotyping, allow me to offer the following suggestion: ask the patient to describe him or herself, and then include the response in the opening statement. Like this:

This is a 50-year-old white female physician blogger with grown children and way too many animals at home who describes herself as "zaftig but generally healthy."

I don't treat diseases. I treat people, and because every person is different, I think it is better to err on the side of more description rather than less.

Secret Handshake

It turns out this crotchety old guy in his 80's whom I've known for years has a sister, also in her 80's, whom I've known for just as long. Listening them to them bicker squabble talk like kids 70+ years their junior is hilarious.

They have this secret handshake from their first childhood. It's in German, because they were born in Vienna, Austria. I've wanted to get it on video for years, and I finally succeeded (on a crappy phone camera, but so what):



(The best part is at the very end. Play it again if you missed the guy's brutally honest self-critique.)

Can You Say "Slap on the Wrist"?

No matter how much we may want them to, some things never change.

Conspiracy to defraud either Medicare or Medicaid carries a penalty of five years imprisonment and a $250,000 fine.

Oh dear.

Anyone care to guess what the ultimate penalty was for being convicted of 137 counts of fraud, tax evasion and obstruction of justice, including defrauding total of $2.4 million from two non-profit organizations and the Pennsylvania State Senate, living high on the hog on OPM ("other people's money"; that's really what he called it), using taxpayer funds to refurbish a posh Philadelphia mansion plus houses at the Jersey shore and in Florida, while claiming that his only duties as a Pennsylvania legislator were to "show up and vote," and that, "There's a law against spitting on the sidewalk, but it's never enforced," when confronted with the relevant code of ethical conduct?

U.S. Probation Department guidelines call for imprisonment of 21 to 27 years, but the judge ruled that they really only call for 11 to 14 years.

The sentence was handed down yesterday: 55 months. Four years and seven months.

Let me get this straight: defrauding Medicare (only once) gets you 5 years. Defrauding the taxpayers of Pennsylvania of millions of dollars (somewhere between $2.4 and $4; exact numbers appear to be hard to come by) is only a scosh more than four and a half. This despite the fact that the other guy who defrauded one of the same non-profits of $2.6 million is serving 15 years, and a former Philadelphia city treasurer is serving 10 years for collecting "only" 10's of thousands of dollars.

Pennsylvania. What a place. I guess some things really will never change.

Living Well

Sing it, sister:

Somewhere along the way in our News You Can Use culture, good health has taken on the patina of virtue. Like good grades and job promotion, health is seen as bestowed upon those who work for it. There's no excuse for not doing everything you can...

As I have intimated previously:

The flip side of this is the judgment passed on those who get sick. They must have done something wrong, their diet must be flawed or they are overweight or drink too much or don't drink enough. Weight is the easiest handle for bestowing blame because we can see it and because we have been taught to associate all manner of poor habits with excess weight.

News flash: life is for living. Although I and others have found our life's calling to be in health care, that doesn't mean that everyone else has to spend every waking minute thinking about what I, as their doctor, might have to say about how they live their lives. So why do they?:

We take our medicine with a side order of morality because it is within the doctor's office and the hospital that scores are tallied and winners are distinguished from losers. Scores must be tallied somewhere, otherwise there would be no reward for all the hard work of keeping healthy, no prize for all the self-denial of doing everything right. We did not pass up all those rich desserts for nothing.

Amen.

Read the whole thing.

(h/t Jockette)

Modern Communication

Time: Few years back, on a Saturday afternoon
Place: My house
Characters: the Jock, the then-Nestling/now NinjaBaker, moi

Scene: Me at the family room computer, the Jock on the couch behind me playing online games on his laptop connected to the house wireless network, the Nestling upstairs on another computer

Me: Hey, Jock; wanna go out to dinner?

Jock: Sure.

Me: Is it okay if we go really early? Like 4:30? It's the best way to beat the crowd on a Saturday.

Jock: Okay.

(a few minutes later)

Me: Can you go upstairs and ask the Nestling if that plan is okay with him?

Jock: Oh, he's fine with it.

Me: What?

Jock: I asked him in chat. He's fine with it.

Translation: even when sitting in the same house, communication by computer is preferred, more efficient, and, I must admit, quieter.


Scene II, present day, planning a trip northwards to visit my sister, the Jockette, but not quite as far north to where the NinjaBaker is spending the summer. The plan, though, is for him to come down and join us for a nice dinner out.

As a good parent (of a good kid), I want to give him a head's up on how to be appropriately attired for the occasion. I also need to know how to pack for myself. Hence the following email exchange:

To Jockette (cc NinjaBaker):

How fancy (or not) is the restaurant for Sunday dinner? As in, what level of dressed-up-ness is required? Asking for purposes of packing. (Please "Reply All" for NB's benefit)

Reply:

Pants or nice shorts, and a button-down or polo shirt or nice soccer jersey is fine. I would avoid sweats or athletic shorts.

Wonderful. Then I look at the cc line:

• NinjaBaker - good
• NiecelingJock
• NephlingHunk

She's also cc'd her own kids to let them know what to wear too.

Are they grown, with homes and families of their own, so that email is the best way to get them the information without interfering in their busy lives?

No.

Are they college students far from home who also need packing cues?

No.

They are 12 and 15, and live at home with her and their father (who are married; to each other; for 19 years next month.) Okay, so it's a big house. But srsly.

I Figured This One Out

Thanks to Professor B who sent me this internet puzzle:

"Regifting Robin"

It's one of your basic "think of a number" games where the computer appears to read your mind.

The original email was titled, "Tell me how this works," so I did. Took me about 5 minutes. Non-mathematical hint available.

(NinjaBaker: consider the gauntlet thrown.)

Oh yeah: I'm a Woman

There has been a nice bit of buzz (thanks for all the comments!) from my recent announcement of the upcoming release of my book. Not just my discarding of the protective illusion of anonymity, but the revelation of my gender. No, I am not of the penile persuasion. Indeed, I am a member of the booby brigade.

I should point out that those who came to the wrong conclusion on this topic, although the victims of their own false assumptions, were given no quarter from moi. From the beginning, I have intentionally blogged with carefully chosen gender-neutral language. At first, it was just for fun. Later, it became practice for the novel I'm writing, as the plot depends on the reader making certain false assumptions the first time through; think The Sixth Sense. (Another example here.)

The closest I have come to dishonesty is simply not correcting those who referred to me in the masculine. My ongoing justification is that gender (mine, at any rate) is irrelevant to what I have to say as a board-certified solo family practitioner. Certainly there have been times when culturally based gender assumptions might have detracted from a given point I may have been trying to make. In that sense I admit to have taken advantage of false assumptions. However I submit that my purpose is to have my words taken at face value, rather than distorted by possibly less-than-favorable cultural assumptions.

I was never really anonymous, and I knew it. I have friends and patients who read the blog. My family reads it. (My sister even leaves comments under her own appropriately ambiguous pseudonym.) My children read it! I could never write anything I didn't want one of them to read, and that, of course, will never change. However now that I am "out", I have no intention of altering my blogging style, except perhaps to post more frequently on writing topics. My hope is that all of you continue to find my blog engaging and interesting, whatever the gender of the person behind it.

Anonymity and Virginity

Question: What do anonymity and virginity have in common?

Answer: You can only lose them once, so make it count.

I am pleased, proud and thrilled to announce the upcoming release of my first book. From Kaplan Publishing, on August 4, 2009:

DECLARATIONS OF A DINOSAUR;
10 LAWS I'VE LEARNED AS A FAMILY DOCTOR
by Lucy E. Hornstein MD

Yes, it's based on the Laws of the Dinosaur (newly updated) from the sidebar (look over there ==>).

Here's the blurb:

Solo family doctor Lucy E. Hornstein MD looked forward to practicing medicine since childhood. But somewhere between hanging out her shingle and the realities of 21st century medicine, she found herself becoming more and more of a dinosaur. With insight, warmth and biting wit, she shares her unique take on medical practice in DECLARATIONS OF A DINOSAUR: 10 LAWS I’VE LEARNED AS A FAMILY DOCTOR.

Borrowed, adapted and made up, each law contains the seed of a greater truth about modern outpatient medicine. With clarity and humor, Dr. Hornstein relates the growing frustration caused by insurance companies, specialists and unreasonable patients that has led so many other solo docs to throw in the towel, while she continues to battle it out on her own.

Illustrated at every turn with stories, vignettes, and anecdotes drawn from real life, Dr. Hornstein will have you chuckling at the ignorant advice from the guy in the health food store, and laughing aloud at the forthright pronouncements of her college genetics professor. Even while drawn into the trials and tribulations of solo practice, the reader will feel Dr. Hornstein’s fulfillment of her calling, as her joy shines through on every page.

For those faithful readers (both of you) who tune in regularly, you should know that the book consists entirely of new material that has never appeared on the blog. So even if you've read every word of my 700+ posts to date, you can still buy the book and be assured of 239 all-new pages of Dinoblather.

Where can you buy it? Anywhere. It can be pre-ordered at Amazon, Barnes & Noble, and elsewhere. If you can wait until August 4th, it will be available in bookstores everywhere.

Stay tuned for news about signings, readings and other events.

Half of the Story

Today's Philadelphia Inquirer has a front-page discussion about expensive surgical interventions in the very aged. They find a few examples of unusually vigorous geriatric patients (including the world-renown cardiac surgeon Michael DeBakey himself, who had an aortic repair at age 97 and lived productively for another two years) and indulge in the usual extrapolation of costs multiplied by the numbers of aging baby boomers. Once again, they get half the story right.

Pennsylvania Hospital's chief of cardiothoracic surgery, Charles Bridges, is correctly quoted thusly:

You have to get out of the idea that there's a threshold age where we think about this surgery differently. With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don't?

This is an accurate statement of the clinical reasoning required in these scenarios. I agree that there is no arbitrary age threshold above which any given medical intervention should be withheld. Treatment needs to be individualized based on the clinical condition of the patient.

The actual problem is that people in really crappy condition undergo all kinds of heroic interventions all the time, because they're "so young!" Or because some hotshot surgeon thinks he can pull them through, because, yanno, his skills are so extraordinary they can overcome the effect of years of diabetes, smoking and inactivity. (Hint: no, they can't.) Or because the family feels so guilty about neglecting poor demented granny in the nursing home that when she becomes septic and her kidneys fail, of course she need dialysis! You can't let her die!!

There's another great line further on in the article:

[We] are all suffering from a terminal, sexually transmitted disease called life.

So true, yet so difficult for Americans to accept.

A better way to address the issue of health care rationing (yes, I said the r-word) is to base treatment decisions on the patient's clinical condition. Things like whether or not they are still working (like my 81-year-old father), their mental status (why are we performing elective procedures on patients with advanced dementia?), and their co-morbidities (there's a huge difference between the active 85-year-old on only 1 or 2 meds -- yes, they exist -- and the bloated, diabetic, smoking couch potato in his 60s).

A cost-effective, medically appropriate way to address this issue is to curb overtreatment in those patients with advanced dementia and multiple co-morbidites, whatever their age. They are the ones who make all this expensive technology respectively futile and dangerous. Both patients and doctors need to get over the mentality that just because something can be done, it ought to be done. This includes eliminating so-called "screening" tests like annual echocardiograms and stress tests for anyone who's ever seen a cardiologist. It means not starting kidney dialysis in the face of advanced dementia. Perhaps it even means not transferring septic nursing home patients to hospitals in the first place.

We shouldn't be arguing about operating on healthy 90-year-olds. It's the frail, fragile folk in their 70's and younger, bodies wrecked by years of abuse, who ought never to see the inside of an OR in the first place, but who all too often are whisked there without a second thought. We need to start telling the other half of the story.

Ad Shame

Doesn't anyone have any shame anymore?

Apparently some people still do. PalMD of White Coat Underground and Orac of Respectful Insolence have recently seen the light. More specifically, they've seen the ads on their blogs placed there by automated algorithms that supposedly select ad content based on the content of the blog posts, and have been appropriately ashamed and appalled.

It turns out that the results of those automated algorithms are embarrassingly inaccurate. Most of the time, they come up with ads for the very things -- chiropractic, colon cleanses, homeopathy, all kinds of alt med woo -- that are being ridiculed, taken to task and otherwise being deconstructed in the very posts they appear beside.

Unfortunately there is another blog, one that prides itself on its skeptical slant to the point that its name is actually "Science-Based Medicine," that has had these ads on the blog's sidebar from its inception. Worse, I've pointed it out to them. Several times. To more than one of them. Their answers ranged from, "Our webmaster can't do anything about it," to "We trust our readers to understand that we don't choose the ads and that we don't endorse their content."

cough*rationalization*cough

Doesn't even the appearance of conflict embarrass them? That's why I don't have any ads on my blog at all, and I don't think I ever will. There are better ways to make money from writing than passive income from ads for quackery, and there are better reasons to write blogs than to make money. Or at least there ought to be.

We need to be clear not just about what we're doing when we blog, but why we're doing it. Some of the SBM editors have pointed out to me that their blogging takes time, and their expertise is their stock in trade. Blogging costs money (actually, it doesn't have to, or it can cost very little), time is money, and therefore revenue from the ads is justifiable.

I call bullshit.

If you're a doctor like me, you make your living taking care of patients. Ditto if you're a nurse. If you're a doctor who does research, then you are paid by your grants. Writing (which includes blogging) is not the equivalent of patient care. It is possible (and a lot of fun) to be paid for writing, but entering into a contract to be paid a certain sum for writing a something specific is not the same as passively collecting revenue from sidebar advertising on a blog. It's kind of like charging rent to leeches for allowing them to suck your blood.

So Kudos to PalMD. Orac, I'm reserving judgment. Although he states his tolerance will be zero by Monday, I wonder what -- if anything -- he will do about Science-Based Medicine. As it turns out, he blogs there too.

Tall Tales

Cute: