Where’s Waldo???

The better question is, in my opinion, WHERE'S THE CEO? The recent article in the Tribune http://www.news-tribune.net/local/local_story_179171429.html
certainly had few positive things to say about the current financial situation at Floyd.

This is the first time in probably a decade that Floyd has had to make substantial cuts in hopes of meeting the projected budget. The CEO rarely declines the opportunity to claim credit when there are positive things happening, but where was he for this interview? I’m sure I saw him in town, and I’m pretty sure I saw him the morning of this article. But I guess he was too busy for the interview. Or maybe they drew straws and the VP got the short one.

This article, in my opinion, is another prime example of skirting responsibility when things are on the downturn.

In addition, the VP did a good job of explaining the problems and you’ve heard all of these things before. Outpatient procedures are down. Surgeries are down and projections for the new addition aren’t being met.

The reporter should have continued this line of questioning and asked why? We have more physicians than we’ve ever had and the population is growing. Could it be the physicians are unhappy and maybe doing things elsewhere? Could this administration actually be driving more physicians away? Is this administration costing Floyd more in lost revenue than they are worth? Are the continued bed crunch and diversion issues still causing more problems than the administration will admit? There could have been many more in-depth questionS that may have shed some light on the real problems.

In addition, this VP was able to give a clear explanation of what the CEO was unable to explain at the last staff meeting. Directors were asked to cut 5 percent from their budgets not 2 percent as the CEO told the Medical Staff. The goal was to cut the overall budget by 2 percent. Maybe the CEO just didn’t understand the numbers or the cuts.

Word on the street now is that the administration is telling the Board they need more beds. Imagine that, after a $65 million dollar expansion.

Our nations security

Our nations security does affect our health. The following letter was sent out by Scott Jennings, White House Office of Political Affairs. I am pretty sure it won’t get printed in too many newspapers.

Letter to the Editors of The New York Times

by Treasury Secretary John W. Snow

Mr. Bill Keller, Managing Editor

The New York Times

229 West 43rd Street

New York, NY 10036

Dear Mr. Keller:

The New York Times' decision to disclose the Terrorist Finance Tracking Program, a robust and classified effort to map terrorist networks through the use of financial data, was irresponsible and harmful to the security of Americans and freedom-loving people worldwide. In choosing to expose this program, despite repeated pleas from high-level officials on both sides of the aisle, including myself, the Times undermined a highly successful counter-terrorism program and alerted terrorists to the methods and sources used to track their money trails.

Your charge that our efforts to convince The New York Times not to publish were "half-hearted" is incorrect and offensive. Nothing could be further from the truth. Over the past two months, Treasury has engaged in a vigorous dialogue with the Times - from the reporters writing the story to the D.C. Bureau Chief and all the way up to you.
It should also be noted that the co-chairmen of the bipartisan 9-11 Commission, Governor Tom Kean and Congressman Lee Hamilton, met in person or placed calls to the very highest levels of the Times urging the paper not to publish the story. Members of Congress, senior U.S.
Government officials and well-respected legal authorities from both sides of the aisle also asked the paper not to publish or supported the legality and validity of the program.

Indeed, I invited you to my office for the explicit purpose of talking you out of publishing this story. And there was nothing "half-hearted"
about that effort. I told you about the true value of the program in defeating terrorism and sought to impress upon you the harm that would occur from its disclosure. I stressed that the program is grounded on solid legal footing, had many built-in safeguards, and has been extremely valuable in the war against terror. Additionally, Treasury Under Secretary Stuart Levey met with the reporters and your senior editors to answer countless questions, laying out the legal framework and diligently outlining the multiple safeguards and protections that are in place.

You have defended your decision to compromise this program by asserting that "terror financiers know" our methods for tracking their funds and have already moved to other methods to send money. The fact that your editors believe themselves to be qualified to assess how terrorists are moving money betrays a breathtaking arrogance and a deep misunderstanding of this program and how it works. While terrorists are relying more heavily than before on cumbersome methods to move money, such as cash couriers, we have continued to see them using the formal financial system, which has made this particular program incredibly valuable.

Lastly, justifying this disclosure by citing the "public interest" in knowing information about this program means the paper has given itself free license to expose any covert activity that it happens to learn of - even those that are legally grounded, responsibly administered, independently overseen, and highly effective. Indeed, you have done so here.

What you've seemed to overlook is that it is also a matter of public interest that we use all means available - lawfully and responsibly - to help protect the American people from the deadly threats of terrorists.
I am deeply disappointed in the New York Times.

Sincerely,

[signed]

John W. Snow, Secretary

U.S. Department of the Treasury

Nurse ratio bill in Massachusetts

A recent bill in Massachusetts has passed the House of Representatives that would establish “ideal” and minimum nurse-to-patient ratios and also would ban mandatory overtime for nurses. This is similar to legislation already in place in California. Nurses there have also won some key recent court battles validating the legality of the current standards.

Hospitals violating the standards in the Massachusetts bill could face fines or loss of their license. The bill now goes to the Senate, but no formal time frame has been decided.

The Mass. Nurses Association applauded the 133-20 vote while the hospital association reportedly called it “deeply disappointing”. The spokesman for the hospital association, Paul Wingle, said, “We cannot or will not accept micromanagement and command-and-control regulation that ties the hands of hospitals.” But they certainly don't mind micromanaging nurses or physicians and continually support measures that does just that.

We have said for years that someone needs to set some minimum standards to protect and maintain appropriate patient care. I have said that Floyd could choose to do this and begin setting some community standards. It would be a great marketing tool and begin to make Floyd a hospital that more and more nurses chose for employment. But under our current administration and their philosophy, this will likely never happen until they are forced to do so.

The Hospital Associations have lots of money and Political Action Committees (PAC’s) on their side and therefore I am sure that this fight is not over in California, Massachusetts or elsewhere.

Does the statement above from the Hospital Association really make you believe that patient care is their first priority?

Purpose statement

Since it has been nearly nine months since starting this blog, I thought it would be helpful to some of our new and loyal readers to re-iterate the purpose.

We have and will focus on numerous topics that affect our lives including personal choices, morality, education, routine health care issues and of course the issues related to the Hospital. Some topics will be humorous, others fun and lighthearted, and still others very serious. Each is given from my perspective and with my opinion and some will agree while others will not.

I have major concerns about the current structure and political issues related to our hospital and our healthcare. I was appointed to the Board and served four years until my term expired in January of this year. I was an outspoken critic of the current administration and was very open about the direction I felt Floyd needed to go. I was not reappointed in part because of the controversy I stirred up. I made it very clear to the Board and the CEO that I believed the Hospital would begin to decline if the current CEO remained after the new addition was built.

As the only physician on the Board, I had a perspective and insight that no other Board member had. My replacement on the board by a non-physician has left the Board without an inside perspective and has allowed the CEO to continue to filter the information the Board receives. The medical staff as well as the current Board and the Floyd County Medical Society have all sent letters to the County Commissioners requesting physicians be placed back on the Board. It has been 6 months and the Commissioners have not yet responded; in part because it would it appear as if they made a mistake.

The new addition was a huge financial undertaking and in order for it to succeed, I believed and still believe we would need to partner with physicians in a multitude of areas in order to continue generating the revenue required to meet financial assumptions. It was my fiduciary responsibility to point out the areas of concern. I also believe that most physicians do not trust this administration and will have a hard time partnering for the future success of Floyd.

I accepted the fact that I was in the minority of individuals willing to express the true concerns but I continued to vote on what I felt was best for patient care, the hospital and its employees. I was the sole dissenting vote when it came to giving a raise to the CEO. I was the dissenting vote on funding the legal battle against the private hospital that eventually cost Floyd around a quarter of a million dollars. I continued to address the low patient satisfaction, employee satisfaction, and physician satisfaction numbers from the surveys. I continually brought up the relationship issues that have been so devastated by this administration.

I made predictions that we would continue to lose loyal physicians in partnership arrangements because of the severe lack of trust in the CEO. These were made very openly in Board meetings and other venues. Several of these are identified in previous blogs and many have already come true and there will be more to come.

I never wanted the change in leadership to be a battle and I was very open about wanting a smooth transition of the CEO to begin the new era in the Floyd Memorial history.

Unfortunately, I was in the minority and we could not obtain the majority of votes on this issue. We had and continue to have some Board members who are very nice people, but unwilling to address some of the real issues in a proactive manner.

The Board did approve the budget every year but was very concerned about the budget for 2006. The CEO and CFO lowered the acceptable margin for the first time in all the years I served. We asked how conservative the numbers were and were assured by these individuals that they felt they could be met.

Now at the last staff meeting, the CEO announced we were not even reaching this lowered goal and would need to make additional cuts. The truthfulness of his comments at our staff meeting has already been addressed. The Board meets tonight and will surely talk in length about the financial numbers. Beginning Wednesday or Thursday, I anticipate the CEO will begin sharing the information with the employees.

The one or two critics who continually condemn me and this blog rationalize and make excuses for the performance of this CEO and administration. They continue to comment about the past and how every other hospital is also struggling and how we shouldn't blame this CEO. Yet they are very insecure about discussing the issues and they continue to search for my sources and are committed to finding the leaks. They continue to do this while hiding behind the veil of anonymity. It has been suggested that these anonymous critics are either in administration or represent administration. We’ll let the readers decide.

I chose to allow anonymous comments because I believe that getting the information out and allowing all sides to be heard is beneficial. I could just as easily, with the click of a button, choose to not allow comments. This would have prevented the personal attacks by these one or two individuals, but I think the readers have benefited from hearing the verbal diatribes.

On our present course, we are quickly reaching a point in the finances that more drastic actions may need to be taken. Our bond rating could be affected and if the financial numbers would get to a certain low level, the hospital management could be taken over. These are serious issues that the Board needs to discuss in depth.

No matter what the critics verbalize, I had always hoped that the transition in leadership could be made on mutual agreement, but at the current rate of decline, it may eventually need to be made out of necessity. We cannot continue to lose critical physician relationships and the revenue these relationships bring to the hospital. I’ve stated these things very clearly for more than four years and many of the things I predicted are already occurring.

Complacency, conflict avoidance, and ignoring the obvious will continue to wreck the morale of our most important assets; our employees and our physicians. The employees have always been what make this hospital successful. Administrators will come and go, but physicians and employees are the foundation of this great institution. My goal is to see it stays that way!

OB's turn down offer

We have talked before about the importance of relationships and how minimizing or marginalizing them is in fact a detriment to Floyd Memorial. Many critics always act as if it is purely monetary issues that drive physicians away from Floyd, but again, the facts do not support the conclusions.

Physicians have chosen to utilize Floyd less and in increasing numbers not because of their financial concerns as much as the severe and ongoing mistrust and poor relationships they have with the current leadership as well as not having their needs met for their patients and themselves.

A perfect example is from the OB/GYN physicians who have struggled with the exorbitant cost of their malpractice. Floyd was asked months ago if they could assist in any way and initially did not give them a very favorable response. When Floyd heard they were looking elsewhere, and when it was clear that they became involved in the competing surgical center that will be built, Floyd finally did find a way to offer them assistance with their malpractice expense. The OB/GYN’s have since turned down the offer even though it would help their financial situation tremendously.

If it were just about money, as a few continue to suggest, then they would have immediately accepted the offer and taken the money.

It is not about money. It is about patient care, quality of services, and the relationship of those you choose to partner with. Physicians aren't choosing to partner with Floyd. There is a reason and the Board should be asking the question.

Just because the administration and Board cannot place a dollar value on the relationship it has with physicians does not make these relationships worthless. When more relationships are destroyed and more physicians find alternative and better ways to meet the needs of their patients, the hospital will continue to see the true cost of these lost relationships.

If Board members and Commissioners would really ask questions that mattered and really seek input about the problems, maybe they would be willing to make some changes. It has been suggested numerous times for a small group of Board Members to meet with physicians privately to hear their concerns. But this has never happened in the absence of the CEO.

So for now, everyone just ignores the great white elephant in the living room and makes excuses for what they know to be the truth. I’ve said before; it is either to avoid conflict for most people than to resolve conflict.

Joslin Center

The Joslin center at Floyd Memorial continues to be a true asset to the community. They recently received another three year accreditation from the American Diabetic Association (ADA).

The staff continues to provide the most complete, comprehensive and personalized care of any diabetic facility in the area. This is the one area of Floyd that actually brings patients from Louisville across the river.

They provide a service to physicians that remains unmatched and we certainly appreciate the exquisite care our patients receive. This is especially true for the very difficult to manage diabetics.

This is another area that has been labeled as money-losing by the administration. The staff has worked very hard to find new creative ways to generate revenue. But, there is a value to this department that accountants cannot begin to place a monetary value on and if this center is lost, it would be devastating to the healthcare of our community.

If any reader has had personal experiences at the Joslin Center, please feel free to comment and contribute to maintaining this wonderful program.

Definitions

Let’s review some definitions:

1) Lie
A false statement deliberately presented as being true; a falsehood.
Something meant to deceive or give a wrong impression.

2) Equivocate
To use equivocal language intentionally.
To avoid making an explicit statement. See Synonyms (lie)

3) Misstate
state something incorrectly

Tuesday night we had our bimonthly Medical staff meeting at Floyd Memorial and there has been lots of talk among the staff and physicians about what was actually said and what we know to be factual.

The CEO stood up in front of the entire medical staff that attended and reported without specifics that the financials are not at goal and we need to “right-size”. He gave the example of buying a bigger house and how you have to sometimes make cuts to then meet the financial strains. He stated very clearly that “he has instructed all the directors to cut their budgets by 2 percent.” He also made statements saying it should not affect patient care areas or nurse to patient ratios.


First off, the directors have reported they were instructed to cut budgets by 5 percent not 2 percent. So, as one of the news stations say "We report, You decide". We'll let the readers decide as the physicians have which definition this describes. The problem is not the size of the cut, but it is whether the information recieved from certain individuals can be trusted. Physicians are unwilling to partner with people they cannot trust.

From a business perspective, when you tell each department the goal is to cut the budget, they really only have one major way to do that. Cut staff, hours and services. The goal should be to increase revenue and find ways to generate more income not just to cut costs.

So what has happened? Directors have and will cut their budgets, but by doing so we are losing good employees and nurses. Some have decided to transfer to other non-patient-care departments because the nurse-patient ratio is too high and they do not feel they can provide the care they want, some long term employees have been fired for various reasons, and some employees will just choose to leave.

Surgery made a unilateral decision to cut the time by two hours of running 2 OR rooms rather than 1 in the evenings. This was done without even consulting the Chairman of the Department of Surgery. Surgery generates revenue. By cutting the available times surgeons can schedule cases, it will cause a loss of revenue and a loss of good relations from the surgeons. Many surgeons are saying they are just going to do more cases at Clark where they can schedule when they want and not have it affect their personal time as much.

So each department may actually cut its expenses, but by doing so, it may actually cut the overall revenue. You may cut your expenses by 5% and lose 10% in revenue. These are probably not the wisest decisions.

Physicians in many departments had lots of suggestions, but no one felt it was important to ask their opinion and with no physician on the Board, there will be little to no input at that level.

Physician wins defamation lawsuit

The recent article reads “A California appellate court dismissed a defamation lawsuit”. In California, the hospital affiliated group had the lawsuit dismissed and they were ordered to pay the physician for legal and other fees in an amount in excess of $100,000.
http://www.modernhealthcare.com/news.cms?newsId=5275&potId=MN

The physician had questioned the financial solvency of the institution in an email and was later sued for slander. It was a big win for the physician and a big win for free-speech.

Physicians and others should be free to comment and point out inconsistencies and other issues that could directly harm or impair the ability to deliver quality medical care to our patients. We should be able to question the legitimacy of decisions related to our hospital. As physicians, we have a perspective that most others will never understand or appreciate and therefore a responsibility to help direct decisions in ways we believe to be most beneficial. When these challenge current ideas and thinking, they need to be openly discussed and people need to be held accountable for their decisions and actions.

Here locally, we have a county-owned hospital and there is very little information that the public is privy to. Physicians and employees have few venues to discuss issues of importance. Until about 4 years ago, even the County Commissioners received very little communication about the hospital, its finances, or other issues because of the control the administration maintained.

Many people have been enlightened with the ongoing discussions but there continues to be behind-the-scenes comments about how much information is being shared and whether I have overstepped the current boundaries. I think the controversy itself shows the degree of distrust that so many people have regarding this administration and the degree some are going to try and silence the detractors.

I have always believed that if you provide individuals with enough legitimate and accurate information, they will make the right decisions. It is the continued biased and selective information provided that has caused so many poor decisions to be made in the hospital’s past and this needs to cease. Board Members, Commissioners, and the public need to be better informed and have all the information presented. This hospital is owned by the taxpayers and therefore should be responsive and open to them.

Coffee cutting measures

Employees are getting a little more anxious with the smoking ban coming down to the last few days. Floyd will go completely smokeless as of July 1, 2006.

Directors are meeting with their departments and really putting some fear in the employees about the current financial situation at Floyd. They are looking for ways to cut costs and employees recognize this phraseology as employee cut-backs.

It has gotten to the point that employees are hearing they are considering eliminating the free coffee. They are reportedly surveying how many employees are drinking coffee and tea.

Employees are saying “they took away our smokes and now they’re taking away our coffee!”

As you can imagine, this is not a big morale booster.

The financials continue to slide and the number of heart cases is well below projections. Rather than cutting out the free coffee, how about a “no bonus” consideration for the administration. What are the odds of that happening?

Defensive Medicine

A recent investigation from the “Annals of Emergency Medicine” suggests that defensive medicine is being practiced more often than previously thought. Is this a bad thing and should it be changed?

So what is defensive medicine? Most professionals define it as the use of diagnostic tests and treatment measures primarily for the purpose of averting malpractice lawsuits. Although only a few physicians may admit that malpractice concerns are the reason for their decisions to admit a patient to the hospital or to order a specific test, data on triage and test ordering decisions in real life cases suggests that malpractice concerns are a much greater factor than physicians acknowledge.

Emergency Departments are a setting where defensive medicine is more likely to be practiced because emergency physicians are under considerable stress and must make decisions quickly. In addition, the ED is particularly susceptible to malpractice suits because there is limited opportunity for physicians to develop a relationship of any meaning with the patient or family. Other specialties in similar situations that may also practice defensive medicine is anesthesiology, radiology, and obstetrics.

Other recent studies include the June 1, 2005 JAMA article and the July 13 Annals article. These studies focused on a particular problem and looked at actual physician decisions. These studies support the fact that many patients are treated and admitted to hospitals for assurance reasons rather than actual clinical indications.

What these studies do not clarify is what the “standard of care” is for those particular areas. If attorneys can show that a physician deviated from the local "standard of care", then the physician can be held negligent. It really makes no difference if the literature supports your decision making. There are plenty of “hired guns” who are more than willing to testify that a physician deviated from the standard of care.

This study also went a step further and physicians were surveyed and categorized into high, medium, and low fear groups. In the analysis of patient records, the study determined that physicians with the greatest fear of malpractice were less likely to discharge low-risk patients compared with physicians with low malpractice fear. High-fear doctors were more likely to admit low-risk patients and to order additional tests compared to their colleagues.

Even though emergency physicians must see all patients regardless of how risky a patient’s case may be, the goal for each physician should be to make sure those patients are being treated appropriately and receiving the “necessary tests.” But what are necessary tests and who makes this decision. It is easy for third parties to look in retrospect and pass judgment. It is very different when you are on the front line dealing with the emotions of the families and patients along with the medical problem.

Focusing on mechanisms to improve patient safety at the hospital and institutional level as well as having physicians take an active role in this problem is a very important step. Nothing will happen with any significance until physicians can be assured that they are protected in some manner. Until then, the cost of defensive medicine will continue to rise.

Happy Father's Day

As I reflect on Father’s Day, I have mixed emotions. It has been more than eleven years since I lost my father at the young age of 54. God blessed my family with a Dad that showed unconditional love. He is still missed everyday and there is a hole left in my heart that will never be filled. I cherish my memories and all of the wonderful times we shared but continue to miss the adventures we could have had.

But God also blessed me with 4 wonderful kids and one grandchild so far. I strive to be the father to them that my dad was to me.

God continues to bless me with friends who also teach me about what it is to being a dad. I continually strive to meet the expectations of being a husband, father, provider and friend and admire my friends who also battle the cultural influences that undermine our traditional family values.

I want to offer a special thanks to my friends like Rodney S., Bill C., Scott W., Jeff W., Tim R., Tod T., Bob M., Stuart E., and Jim R. These men have been friends, inspiration, and each has struggled with different life circumstances but each continually strive to be good Dads. It is for them and the many others not mentioned that I tip my hat and wish each and every one of the readers a wonderful Father’s Day.

One night a father overheard his son pray: Dear God, Make me the kind of man my Daddy is. Later that night, the Father prayed, Dear God, Make me the kind of man my son wants me to be.
Author inknown

Vaccine fears

Recently our office like many other primary care offices have been seeing more and more parents refusing to allow their children to receive the recommended vaccinations because of fears particularly related to autism.

In our science minded culture, there is ample evidence that contradicts the relationship between autism and immunizations, but this is overcome by fears, hearsay and inaccurate information.

The Centers for Disease Control devotes a lot of time and energy on this topic because of the significant public health concerns. They along with several other institutions of academic excellence all have valuable information listed at the sites below:
[NIP: Vacsafe/Concerns/Autism/FAQs-Autism and MMR]
http://www.immunizationinfo.org/search_results.cfv?search=autism
http://www.pkids.org/index2.htm
http://www.chop.edu/consumer/jsp/microsite/microsite.jsp?id=75918
[NIP: Vacsafe/Concerns/Autism/Research-Vaccines and Autism]
[NIP: Data & Stats/Main page]

Many parents as well as physicians in this generation have never seen a case of measles, mumps, rubella, or pertussis. But those of us who have can verify the severity of the diseases and associated complications.

The fact that many have never had first hand experience with these diseases has led to complacency and allowed unsubstantiated fears to overcome better judgment.

Here are some statistics:

Diphtheria
Diphtheria is a serious disease caused by a bacteria. This germ produces a poisonous substance or toxin which frequently causes heart and nerve problems. The death rate is 5 percent to 10 percent, with higher death rates (up to 20 percent) in the very young and the elderly. In the 1920's, diphtheria was a major cause of illness and death for children in the U.S. In 1921, a total of 206,000 cases and 15,520 deaths were reported. In 2001 only two cases were reported.

Mumps
Before the mumps vaccine was introduced, mumps was a major cause of deafness in children, occurring in approximately 1 in 20,000 reported cases. Serious side effects of mumps are more common among adults than children. Swelling of the testes is the most common side effect in males past the age of puberty, occurring in up to 20 percent to 50 percent of men who contract mumps. An increase in miscarriages has been found among women who develop mumps during the first trimester of pregnancy. An estimated 212,000 cases of mumps occurred in the U.S. in 1964. If we were to stop vaccination against mumps, we could expect the number of cases to climb back to pre-vaccine levels, since mumps is easily spread among unvaccinated persons

Pertussis
Pertussis can be a severe illness, resulting in prolonged coughing spells that can last for many weeks. These spells can make it difficult for a child to eat, drink, and breathe. Because vomiting often occurs after a coughing spell, infants may lose weight and become dehydrated. In infants, it can also cause pneumonia and lead to brain damage, seizures, and mental retardation. Before pertussis immunizations were available, nearly all children developed whooping cough. In the U.S., prior to pertussis immunization, between 150,000 and 260,000 cases of pertussis were reported each year, with up to 9,000 pertussis-related deaths. Pertussis cases occur throughout the world. If we stopped pertussis immunizations in the U.S., we would experience a massive resurgence of pertussis disease. A recent study* found that, in eight countries where immunization coverage was reduced, incidence rates of pertussis surged to 10 to 100 times the rates in countries where vaccination rates were sustained.

*Reference for study: Gangarosa EJ, et al. Impact of anti-vaccine movements on pertussis control: the untold story. Lancet 1998;351:356-61.

Measles
In the U.S., up to 20 percent of persons with measles are hospitalized. Pneumonia is present in about six percent of cases and accounts for most of the measles deaths. Although less common, some persons with measles develop encephalitis (swelling of the lining of the brain), resulting in brain damage. As many as three of every 1,000 persons with measles will die in the U.S. In the developing world, the rate is much higher, with death occurring in about one of every 100 persons with measles. If vaccinations were stopped, each year about 2.7 million measles deaths worldwide could be expected.

Polio
Polio virus causes acute paralysis that can lead to permanent physical disability and even death. Before polio vaccine was available, 13,000 to 20,000 cases of paralytic polio were reported each year in the United States. These annual epidemics of polio often left thousands of victims--mostly children--in braces, crutches, wheelchairs, and iron lungs. The effects were life-long.

Haemophilus
Before Hib vaccine became available, Hib was the most common cause of bacterial meningitis in U.S. infants and children. Before the vaccine was developed, there were approximately 20,000 invasive Hib cases annually. Approximately two-thirds of the 20,000 cases were meningitis, and one-third were other life-threatening invasive Hib diseases such as bacteria in the blood, pneumonia, or inflammation of the epiglottis. Hib meningitis once killed 600 children each year and left many survivors with deafness, seizures, or mental retardation. Since introduction of conjugate Hib vaccine in December 1987, the incidence of Hib has declined by 98 percent. From 1994-1998, fewer than 10 fatal cases of invasive Hib disease were reported each year.

Traffic Accidents
Traffic accident deaths account for 41% of all accidental deaths in children. In the US, an average of 6 children 0-14 years old were killed and 694 injured every day in motor vehicle crashes. Traffic accidents are the leading cause of accidental deaths in children. How many parents allow there children to ride in cars?

Fires
Fires kill more than 600 children ages 14 and under each year and injure approximately 47,000 other children. How many of families keep and maintain smoke detectors in their homes and keep fire hazards away from children?

Drownings
In 2003, there were 3,306 unintentional fatal drownings in the United States, averaging nine people per day. This figure does not include drownings in boating-related incidents (CDC 2005). 67% of all drowning deaths occur in their own backyard pool, spa or hot tub. The majority of drowning incidents occur while the caretaker assumed the child was safely indoors. For every drowning, an additional five near drowning cases are treated in the emergency room. Irreversible brain damage occurs in 3 to 5 minutes. How many have swimming pools in their backyards or neighborhoods?

CDC Statements on Autism

It is not known how many children in the United States currently have autism or a related disorder. Studies done in Europe and Asia indicate as many as 2 out of every 1,000 children have some type of autism.

A recent investigation by CDC in Brick Township, New Jersey, found a prevalence rate for the autism of 4.0 per 1,000 children and a rate of 6.7 per 1,000 children for the more broadly defined category of autistic spectrum disorders. Although the rates obtained in Brick are high compared to other published reports, it is important to keep in mind that there are no current rates for autism from the United States.

Furthermore, investigators in other countries who used intense case finding methods in small communities are finding rates of autism in the range of those found in Brick Township. The interpretation of the results from the Brick prevalence investigation will not be fully understood until additional prevalence rates have been obtained from other communities and compared to those in Brick Township.

CDC runs the Metropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP), one of the few programs in the world that conducts active and ongoing monitoring of the number of children with developmental disabilities in the multiracial Atlanta area. CDC added autism to the program in 1998 and anticipates having prevalence rates for autism in the fall of 2000.

Autism is a spectrum of disorders that are complex and lifelong. Individuals with autism have problems with social interaction, communication difficulties, and restrictive or repetitive interests/behaviors. Autism Spectrum Disorders (ASD) includes autistic disorder, pervasive developmental disorder - not otherwise specified (also known as atypical autism), and Asperger’s disorder as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual - Fourth Edition (DSM-IV).

Children with autism require long-term care and services. Special education costs for a child with autism are more than $8,000 per year, with some specially structured programs costing about $30,000, and care in a residential school costing $80,000 - $100,000 per year.

Little is known about causes of autism, although genetic and early prenatal exposures have been suggested. There is no cure for autism. However, early and intensive education can help children develop skills and reach their potential. Although available medicines cannot cure autism, some may relieve symptoms associated with the disorders.

Summary

While, it is clear that more children than ever before are being classified as having an Autism Spectrum Disorder, it is unclear how much of this increase is due to changes in how we identify and classify ASDs in people, or whether this is due to a true increase in prevalence.

Autism is real and for those affected it can be devastating. But to allow a resurgence of these other diseases is not a good choice when the current evidence does not substantiate the fears.

Information sources: CDC, NIH

AMA news

Physicians are certainly in favor of health coverage for all citizens, but the AMA’s announcement is somewhat vague.

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  June 13, 2006
  
  At its annual meeting today, the American Medical Association endorsed requiring individuals and families to obtain basic health care coverage as part of a legislative approach to covering the nation’s more than 46 million uninsured residents. The association said individuals and families earning more than 500% of the federal poverty level ($49,000 for an individual and $100,000 for a family of four) should be required to obtain a minimum of catastrophic health care and evidence-based preventive health care, using the tax structure to achieve compliance. The association said it would support a similar requirement for those earning less than 500% of the poverty level once a system of refundable tax credits or other subsidies to obtain health care coverage was implemented. The AMA said it will advocate for legislation that includes tax credits for the purchase of insurance, individually selected and owned health insurance, the expansion and formation of new health insurance options, changes in health insurance market regulations, and individual responsibility.

Should the government require citizens to purchase health insurance as stated? States certainly require you to have minimal car insurance for the privilege of driving, but requiring families to purchase health insurance is questionable. After all, living is not a privilege, or is it?

What does “using the tax structure to achieve compliance” really mean.

Many questions and not many specifics.

More cardiology discontent

As a follow-up to yesterday’s cardiology discussion, I was informed by one of my colleagues that Floyd sent some of the cardiologists to out-of-town facilities to train on a new type of CT machine that does angiography. This is basically a non-invasive way to look for blockages in the coronary arteries without having to undergo a Cardiac Catheterization. It is ultimately safer for patients but has not gotten widespread use because of insurance reimbursements to hospitals.

The cardiologist took time away from their office, patients and families to train on this certain machine and now that they have returned, they were informed the Hospital decided to buy a different machine than the one they trained on.

They never asked for input or direction; they just made another unilateral decision.

This is very similar to the other incidents within the past year or so where they had asked the ER doctors for input on the computer system in their department, sent them out to other facilities to evaluate but never informed them they had already purchased it before they went.

Or when they replaced the orthopedic equipment without input from the orthopedic surgeons or when they asked the radiologists for their input on the systems in their department but then chose the system they least liked.

It didn’t matter that they wasted the physician’s time and cost him money.

It is just another example of poor communication, lack of respect for physicians, and another way to show how little they value relationships.

The trend continues!

ADDENDUM: 2:15 pm

Trying to be factually accurate, I did recieve input this afternoon that the actual purchase of the ER system was after the physicians visited the site. The ER doctors perception remains that the decision to purchase the system was made before the site visit.

Loyalty Lost

Cardiology has been one of Floyd Memorial Hospitals’ most stable physician groups. We have been lucky enough to have two main groups very dedicated to Floyd and performing the vast majority of their procedures here. Both groups have been actively recruiting new physicians and one group has two new physicians joining and the other group is looking for their third associate. This would bring our primary cardiologists to a total of nine if they are able to recruit to their groups.

It takes a lot of time, effort, and money to recruit and build the practice of a new cardiologist and there are only a fixed number of patients and referrals from this area. It is unlikely that many Kentucky patients will come to this side of the river for their cardiac care.

Recently, these two cardiology groups had gotten word that Floyd was considering a recruitment package for some cardiologists who are now practicing in Louisville. These cardiologists would directly compete with the current two groups and basically dilute the fixed number of patients between additional cardiologists. This would result in lost revenue for the current groups and a more difficult time for their new members to build a practice.

This has caused some very emotional responses by all parties involved. It has contributed to the increasingly tense relationship between physicians and the CEO. The trust issue continues to decline because of repeated poor choices.

The CEO reportedly told one of the cardiologists that he was directed by the Board to increase the Cardiology numbers because they continue to be below the projections. This is of questionable accuracy because the discussion came up last year when I was on the Board and we specifically voiced our opposition to recruiting a competing group of cardiologists. We knew that it would destroy the working relationship we currently had with our present cardiologists.

But since the the current situation at Floyd is that they are below their projections in cardiac procedures and below virtually all of their financial goals for the year as well as struggling with satisfaction numbers, someone decided to consider a rash decision that in actualilty would probably cause even more lost revenue because of lost loyalty. But like many other decisions, they are very shortsighted.

The cardiologists that were being considered are reportedly very good friends with some of our hospitalists who started last year. If they were to come to Floyd, they would likely get the referrals from the Hospitalists. These are not necessarily new patients to our hospital system, but captive ones by the fact they are admitted here and would normally go to our current cardiologist groups. The hospitalists do not have an outpatient practice and it is unlikely they would get many referrals from the private physicians because our relationships and referral patterns are already established with the current groups.

Luckily, someone has been able to stop this recruitment process, but not before the ill-will and strained relationships between the CEO and physicians worsened. You cannot place a dollar value on relationships, but you can certainly feel the financial impact of broken relationships when referral patterns and loyalties change. This is happening repeatedly because of decisions being made by those in charge.

Why would anyone think it was a good idea to actively recruit competition directed at your two very loyal cardiology groups who have been practicing primarily at Floyd for more than 20 years?

This current situation has caused our cardiologists to think long and hard about their future here at Floyd.

Physicians understand competition and we certainly welcome other physicians on our staff who wish to work hard and build relationships and trust. We do not understand why the Hospital would financially support an endeavor that would directly hurt its current cardiology groups that are trying to recruit themselves and increase the care they currently provide mainly to Floyd.

Hospitalists

We are approaching our first year with having hospitalists at Floyd Memorial. The Board should be requesting some utilization numbers from the first year’s experience.

The primary care doctors have certainly found them to be a benefit as we no longer have to manage patients that are admitted through the emergency room who have no physician on staff. It had gotten to the point where we had to have 3 primary care physicians on-call every night for the emergency room because there could be anywhere from 5-12 patients admitted without physicians.

This became overwhelming for primary care physicians who already had to care for their own patients and then try to make it to their offices on time.

The Hospitalists now manage all of these patients who have no physician. The concern is that they may be utilizing more resources because they don’t know the patient and cannot follow them as an outpatient. Hospital lengths-of-stays and cost per admission may be higher. These are bad trends for a hospital.

The numbers are not yet available but many other hospitals also face this same issue. As you can see from the picture, many hospitals are restructuring the way hospitalists are paid to help encourage better performance. It becomes a difficult problem for hospitals, physicians and patients.


In addition to this, some hosptialists have different referral patterns and if they are not "connected" to the community, they may actually send patients across the river for follow-up care costing the hospital even more lost revenue.

Road Rage

It appears that all the major newspapers and news outlets have picked up on the latest mental disorder; “Intermittent Explosive Disorder.” But is Road Rage really a psychiatric disease or just a way to rationalize bad behavior and shirk responsibility for the behavior?
[CNN.com - Study: 16 million might have road rage disorder - Jun 5, 2006]
[‘Road rage’ gets a medical diagnosis - Mental Health - MSNBC.com ]
[Road Rage Considered Brain Disorder, Study: 'Intermittent Explosive Disorder' Affects 16 Million Americans - CBS News]

I am sending for the official study but looking at what is reported so far, I will have a hard time labeling road rage as a mental disorder.

Here is what is being quoted: "This is a well-designed, large-scale, face-to-face study with interesting and useful results," said Dr. David Fassler, a psychiatry professor at the University of Vermont. "The findings also confirm that for most people, the difficulties associated with the disorder begin during childhood or adolescence, and they often have a profound and ongoing impact on the person's life."

One of the investigators by the name of Coccaro said the disorder involves inadequate production or functioning of serotonin, a mood-regulating and behavior-inhibiting brain chemical. Treatment with antidepressants, including those that target serotonin receptors in the brain, is often helpful, along with behavior therapy akin to anger management, Coccaro said.

Here is where the problem arises. The investigators are making assumptions about serotonin levels. There were no measurements and in fact, there is no reliable way to measure serotonin levels inside the brain. Most physicians believe the levels that can be measured in peripheral blood may not correlate with the level in the brain. In addition, seratonin levels are never routinely measured because of the difficulties in measurement and interpretation. These are just speculations by the investigators with no real scientific proof.

It is also noted that most of these individuals began the problem in childhood. What was the family dynamics leading to the behavior and how were the outbursts handled during childhood? There are just way too many variables that contribute to how people handle stress.

Based on their reports and extrapolations, there could be 16 million people with this disease. Are we ready to allow this type of behavior to be excused by labeling it a mental disorder?

I hope we haven’t gone off the deep end. But then that could be labeled a disease as well.

Beer Goggles

We’ve all talked about it, and we all joke about it, but is there really an entity called the “beer-goggle” effect?

The issue has come up again recently in the news. It is based on a study performed by Barry T. Jones from the Department of Psychology and his colleagues at the University of Glasgow.

In this study, they tested 40 male and 40 female university undergraduates who they found on campus premises. Half of the volunteers had been drinking and half were sober. They were not told the exact truth about what exactly they were measuring so not to bias the answers. The volunteers were told that they were doing market research to help identify different types of student faces. During the study, a few were disqualified because they were either gay, they recognized some of the photos, or they had figured out what the study was really trying to measure.

The volunteers were shown 118 faces (half male, half female) via a laptop computer.

They were than asked to rate the distinctiveness of opposite- and same-sex faces – with questions like how big was the nose, how sparkling were the eyes etc. The results of this part of the study did not show much difference between the volunteers regardless of whether they were completely sober or if they had been drinking.

Next, they asked the volunteers to rate the attractiveness of 114 wrist watches. Here the results did begin to show a slight tendency for the ones drinking to rate the watches as more attractive.

Finally, the volunteers were asked to rate the attractiveness of the opposite sex faces. In this part of the study, it was found that both men and women who had been drinking rated the opposite sex more attractive about 25% more often than those volunteers who were sober.

Currently, it is believed that alcohol acts on an area of the brain called the nucleus accumbens. This nucleus is thought to play an important role in reward, pleasure, and addiction. Although the nucleus accumbens has traditionally been studied for its role in addiction, it plays an equal role in processing many rewards such as food, sex, and video games. A recent study found that it is involved in the regulation of emotions induced by music. It evidently is a very powerful reward center that can be triggered by alcohol which in turn can lead to loss of inhibitions and risky behaviors.

So the current advice is that when you visit the bar, hangout, meat-market or wherever, scope out your potential targets before you put on your beer goggles.

I believe there is a country song about this exact phenomenon.

I wonder if our frineds over at NAC would want to sponser our own Sounthern Indiana clinical trial

666

Since there is a lot of talk about today’s date, I thought we would do a little review on the significance and some history of 666

The number 666 as a representation of evil comes from the Bible in Revelations 13:18 and 14:11 and is reverenced in a few other passages.

Revelation 13:18 (New International Version)
18This calls for wisdom. If anyone has insight, let him calculate the number of the beast, for it is man's number. His number is 666.

Revelation 14:11 (New International Version)
11And the smoke of their torment rises for ever and ever. There is no rest day or night for those who worship the beast and his image, or for anyone who receives the mark of his name."

In verse 13 above, it talks about calculating the number of the beast and specifically says it is man’s number. Over the years and recently because of publicity and movies like the “Omen”, the number 666 has become synonymous with the antichrist.

But what is some of the history behind this number?

In biblical times around the time of the prophet Daniel in the city of Babylon, the Babylonians were known to worship many gods and were considered the principle developers of astrology. They had 37 supreme gods with one being superior and ruling over the others. Their belief system involved numbers as they felt they could identify and possibly control the gods with numbers. They assigned a number to each of the lesser gods up to 36. When you add each number from 1 to 36 you get 666 and this was assigned to the supreme god.



Because there was always fear of the god’s wrath, they made amulets with 6 x 6 matrices of the numbers 1 to 36. This was done because they believed by wearing the amulets, they would provide protection. The numbers were arranged on the amulet so that all the rows, columns and diagonals summed to 111 and the total of all the rows or columns summed to 666.




Creating amulets like these seems to have continued well past the time of Jesus as archeologists have discovered amulets with Latin inscriptions indicating the Romans practiced this as well.




In addition to the Babylonians, there existed an ancient numbers game referred to as gematria. Each letter of the alphabet was given a numerical value and names could therefore be encoded as numbers.

Problems arise because many names can have the same total number depending on the scheme of how it is set up. A good example is Adolph Hitler who in certain numerical schemes circulating on the internet, his total sums to 666.

But to John’s original readers in biblical times it must have pointed to a name that was commonly known and Nero Caesar has been suggested in literature. It has been pointed out by Robert Mounce that "this solution asks us to calculate a Hebrew transliteration of the Greek form of a Latin name, and that with a defective spelling" and when transliterated directly from Latin into Hebrew, the result is 616 which may be why some manuscripts of the bible actually recorded the number as 616.

Irenaeus noticed this in the late second century and recorded it in his “Against Heresies 5.30.” So it is fairly certain that the scribes who copied the book of Revelation were familiar with gematria, and it may well have played a part in John's writing of the book of Revelation. Even so, it is unlikely to ever be proven and may never find a universal acceptance.

Other thoughts related to the numbers 666 is the relation to the common theme in Revelations and the interest in the number seven as the number of completeness or perfection. The number 666 falls short of the magic seven three times over and as William Hendriksen (1939:182) said, it defined its message as "failure upon failure upon failure."

There are many other mathematical interpretations with the numbers 666, but they are all speculation. The important thing for all to remember is the number is meant to characterize the beast; not identify the beast. If it was originally meant to point to Nero Caesar, than the mark characterizes qualities considered evil like those of Caesar whom they felt was evil.

So, historically, this practice probably started with the Babylonians in some form or fashion and has been carried through history until today.

ACP News

The American College of Physicians (ACP) recently met in Philadelphia. At the annual session, they discussed a comprehensive approach to redesign how Internal Medicine is taught, delivered and financed.

They understand the importance of the need to perform a major overhaul because of the looming crisis in primary care and especially Internal Medicine. They clearly see the decline in students desire to enter this field and at the rate of the diminishing programs, we will begin to feel the impact in the next few years. Any change now will not really impact the crisis for upwards of 10 years.

There are three major areas of focus:
1. Internal Medicine resident training
2. patient care
3. reforming the payment system

The statistics showed that in 1998 general Internal Medicine constituted 54% of physicians, but by 2003 that percentage was only 23%. The ACP has noted that the interest in the program began a decline a few years ago and will be critical as the population ages with more complicated medical problems and chronic diseases.

The key issues for the decline were found to be the dysfunctional payment system by Medicare with the other insurers following behind, the training program itself being vastly different than private practice, and the cost and indebtedness of the residents.

The ACP stated the future supply of primary care physicians, especially those in office-based medicine will not be able to meet the growing needs of an aging population.

Through three new position papers, they went on to state that our current system continually places obstacles in the way of primary care physicians, forcing many to choose other venues.

The second position paper states the current payment system limits innovation and devalues the skills and quality services that general internists and primary care physicians provide.

The third position paper speaks to the need of completely redesigning the training program. The overall experience hasn’t changed in years even though there have been major changes in medicine.

The ACP has the right ideas. They need to rapidly implement them as we are already seeing a steady transition out of Internal Medicine and primary care.

Net Neutrality: A Call to Action

I received the following in an email as an Ebay member and thought I would post it because of the serious implications that could follow if we allow these companies and/or government to dictate the future of the internet. Another link with information on this topic is http://www.freepress.net/news/15784

As you know, I almost never reach out to you personally with a request to get involved in a debate in the U.S. Congress. However, today I feel I must.

Right now, the telephone and cable companies in control of Internet access are trying to use their enormous political muscle to dramatically change the Internet. It might be hard to believe, but lawmakers in Washington are seriously debating whether consumers should be free to use the Internet as they want in the future.

The phone and cable companies now control more than 95% of all Internet access. These large corporations are spending millions of dollars to promote legislation that would divide the Internet into a two-tiered system.

The top tier would be a "Pay-to-Play" high-speed toll-road restricted to only the largest companies that can afford to pay high fees for preferential access to the Net.
The bottom tier -- the slow lane -- would be what is left for everyone else. If the fast lane is the information "super-highway," the slow lane will operate more like a dirt road.

Today's Internet is an incredible open marketplace for goods, services, information and ideas. We can't give that up. A two lane system will restrict innovation because start-ups and small companies -- the companies that can't afford the high fees -- will be unable to succeed, and we'll lose out on the jobs, creativity and inspiration that come with them.

The power belongs with Internet users, not the big phone and cable companies. Let's use that power to send as many messages as possible to our elected officials in Washington. Please join me by clicking here right now to send a message to your representatives in Congress before it is too late. You can make the difference.

Thank you for reading this note. I hope you'll make your voice heard today.
Sincerely, Meg Whitman President and CEO eBay Inc.

P.S. If you have any questions about this issue, please contact us at government_relations@ebay.com

Let's keep our internet as free and as unregulated as possible!!

Anthem dictates how we supply phone numbers

Anthem, along with most other large insurers, randomly comes to our office to do chart reviews and grade us on our practice. The letter above was given to my office manager by the reviewer on the day she arrived.

We were informed that we would flunk the review if we didn't change our after-hours answering machine message. We had an emergency number to call for emergencies, but the message didn't say urgent as well as emergent. If we didn't change the message, they would give us an unsatisfactory report.

We had never been informed of this before and the message has basically been the same for the past 12 years.

This same reviewer also gave us an unsatisfactory mark because as she was reviewing the chart on a 77 year old patient, we did not have documented that we discussed her sexual activities and risk prevention for sexually transmitted diseases and pregnancy. When informed that the patient was 77 and had a hysterectomy, she just commented that we were deficient in our documentation.

We did receive an overall high 90's score, but this is an example of a cookbook approach to chart reviews that is another example of what is so frustrating to physicians.

The lack of common sense and independent thought from reviewers and others in the insurance industry continues to be a thorn in our side.

Forecast for FLOYDS KNOBS, IN (on a scale of 1-12):

Today's allergy levels:
Thursday - 5.8/Medium

Today's predominant pollen:
Grass, Mulberry and Hickory/Pecan.