The Newest Element

Lawrence Livermore Laboratories has discovered the heaviest element yet known to science.

The new element, Governmentium (Gv), has one neutron, 25 assistant neutrons, 88 deputy neutrons, and 198 assistant deputy neutrons, giving it an atomic mass of 312.

These 312 particles are held together by forces called morons, which are surrounded by vast quantities of lepton-like particles called peons.

Since Governmentium has no electrons, it is inert; however, it can be detected, because it impedes every reaction with which it comes into contact.

A tiny amount of Governmentium can cause a reaction that would normally take less than a second, to take from four days to four years to complete.

Governmentium has a normal half-life of 2- 6 years; It does not decay, but instead undergoes a reorganization in which a portion of the assistant neutrons and deputy neutrons exchange places.
In fact, Governmentium's mass will actually increase over time, since each reorganization will cause more morons to become neutrons, forming isodopes.

This characteristic of moron promotion leads some scientists to believe that Governmentium is formed whenever morons reach a critical concentration.

This hypothetical quantity is referred to as critical morass.

When catalyzed with money, Governmentium becomes Administratium, an element that radiates just as much energy as Governmentium since it has half as many peons but twice as many morons.

The Science Changes

Here is another example of new data coming out that completely contradicts what we thought we knew.

The data concerns estrogen and breast cancer. It was presented at the 31st Annual San Antonio Breast Cancer Symposium and it suggests that estrogen therapy may be beneficial to controlling metastatic breast cancer.

This new data found that for women that had “developed resistance to standard estrogen-lowering therapy… a daily dose of estrogen could stop the growth of their tumors or even cause them to shrink.” This is completely contrary to popular thought and current treatment in which patients are given drugs to minimize the hormone to avoid the growth of breast cancer in estrogen sensitive tumors.

In the study, participants were measured to see how well their aromatase inhibitor therapy-resistant metastatic breast cancer reacted to estrogen therapy and it was found that both the high- and low-dose treatments led to stabilization or shrinkage of metastatic tumors in about 30 percent of the participants.

Additionally, researchers found that “if study participants eventually experienced disease progression on estrogen, they could go back to an aromatase inhibitor that they were previously resistant to and see a benefit – their tumors were once again inhibited by estrogen deprivation.” When those effects ware off after several months, the researchers hypothesize that the tumors might again respond to estrogen therapy. “Some patients have cycled back and forth between estrogen and an aromatase inhibitor for several years, thereby managing their metastatic disease.” PET scanning was able to predict whose tumor would be responsive to estrogen therapy.

One of the researchers felt optimistic that estrogen therapy might be a preferable option to chemotherapy and may lead to a better quality of life.

Once again, the science as we know it is never static when it comes to medicine.

IMMEDIATE ACTION NEEDED

THIS IS A REMINDER FROM OUR ISMA

PLEASE CALL THE SENATE HEALTH & PROVIDER COMMITTEE!!!

The ISMA Government Relations Department needs your help regarding the ISMA’s efforts to pass legislation regarding assignment of benefits. SB 75 and SB 87 will be voted on by the members of the Senate Health and Providers Committee the upcoming weeks. Please call the Senate Health Committee members and ask them to support SB 75!!

Senate Bill 75
SB 75 is authored by Senator Gard who has worked with the ISMA to introduce comprehensive language regarding the assignment of benefits issue. We support SB75 as outlined below:

Assignment of Benefits - It is important to allow a patient the right to choose where they assign their out of network insurance benefits.

The Bill will not change the patient’s or the insurer’s current financial responsibility for out of network services and will not harm health care networks.

This bill only changes where the reimbursement check is sent.

· The bill requires a provider to notify the patient that they are out of network and that they may be billed for amounts not covered by their insurer.

· If after notification the patient still wants the out of network services, it is the patient’s choice as to whether or not he/she wants to assign his/her benefits to the provider.

Senate Bill 87
SB 87 is authored by Senator Patricia Miller and is opposed by the ISMA. SB 87 is language supported by the Department of Insurance and stops short of allowing the patient to chose to assign the benefits to the provider which means the check still goes to the patient with a note informing the patient the money is intended to pay the provider.

What is more alarming is that the bill contains language that is confusing and could open the door for a ban on balance billing. This is not acceptable in any form.

Please call the following members of the Senate Health and Provider Services Committee and express your support for SB 75 and opposition to SB87:

Patricia Miller, Chair R – Indianapolis 317-232-9489
Ryan D. Mishler R – Bremen 317-232-9443
Jean Leising R – Oldenburg 317-232-9054
Vaneta Becker R – Evansville 317-232-9494
Beverly Gard R – Greenfield 317-232-9493
Carlin Yoder R – Middlebury 317-232-9984
Edward E. Charbonneau R – Valparaiso 317-232-9494
Sue Errington D – Muncie 317-232-9526
Vi Simpson D – Bloomington 317-232-9427
Earline S. Rogers D – Gary 317-232-9491
Jean Breaux D – Indianapolis 317-232-9461

Growing Dissatisfaction

A new national survey indicates primary care physicians are so frustrated by the hassles of medical practice that nearly half plan to stop practicing or reduce their patient loads in the near future.

This study found 78 percent of physicians believe there is a shortage of primary care doctors and 49 percent said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

In that same time frame, other physicians said they would:

• Retire (11 percent)


• Work in a non-clinical setting (13 percent)


• Cut back on patients seen (20 percent)


• Work part-time (60 percent)

This recent survey confirms the 2005 ISMA-commissioned study that stated nearly half of ISMA members who responded that they would retire early, relocate to practice in another state or do something else because of an ever-challenging practice environment.

If physicians hold true to their word in the survey, things could get a lot worse for access and care.

This particular study was based on nearly 12,000 responses nationwide and other interesting statistics from the study revealed:

• 63 percent of doctors said non-clinical paperwork caused them to spend less time with patients.


• 94 percent said time they devote to non-clinical paperwork in the last three years has increased.


• 82 percent said their practices would be “unsustainable” if proposed cuts to Medicare reimbursement were made.


• 33 percent had closed their practices to Medicaid patients and 12 percent closed to Medicare patients.


• 45 percent would retire today if they had the financial means.


• 76 percent said they were either at full capacity or overextended and overworked.

So the question always comes up as to why physicians stick with it? The study found that physicians rated patient relationships highest on the list of things they find satisfying about medicine.

The study also found that more than 84% of physicians have made the same or less for the previous 3 years with the majority taking home less income all while working harder.

Not playing by the rules

Credentialing has always been a major headache, labor intensive and many times a nightmare for physicians and their staff.

With this in mind, the ISMA finally succeeded in creating a 2005 law to simplify the credentialing process for Indiana physicians. Before passage of Senate Enrolled Act 43, insurers and HMOs used a variety of credentialing application forms and it created a lot of work and expense for offices.

Using one standard application form would dramatically simplify the process and the 2005 law directed the Indiana Department of Insurance to develop and implement the form. The form was finally developed by the Council for Affordable Quality Healthcare (CAQH) and referred to as the Universal Provider Datasource (UPD). CAQH is a nonprofit alliance of health plans and trade associations that serves as a catalyst for industry collaboration on initiatives to simplify administration for health plans and providers – with the ultimate goal of improving the health care experience.

The passage of the three-year old law requires insurers and HMOs doing business in Indiana to accept the CAQH form and it allows physicians to enter information just once to satisfy application requirements. The individual Insurers and HMOs may choose to accept the document submitted electronically, meaning you complete the form online, or they may require you to print it and mail it to them.

All of this sounds great and it would simplify the process, but as expected, the Insurers and HMO’s don’t play by the rules. The ISMA has been alerted that various insurers are now attaching amendments to the CAQH form and requiring physicians to complete the additional documents before they can be credentialed. This is no different than what the bill was supposed to fix.

The ISMA continues to work with insurers to resolve this matter because it is contrary to the intent of the 2005 law. That likely will not be successful and there will have to be more time and energy spent enacting new legislation to prevent these ongoing hassles from the Insurance companies and HMO’s.

There are the following sites for Frequently Asked Questions here and access to the CAQH form on the ISMA Web site here.

The Husband Store

A store that sells new husbands has opened in New York City, where a woman may go to choose a husband. Among the instructions at the entrance is a description of how the store operates:

You may visit this store ONLY ONCE! There are six floors and the value of the products increase as the shopper ascends the flights. The shopper may choose any item from a particular floor, or may choose to go up to the next floor, but you cannot go back down except to exit the building!

So, a woman goes to the Husband Store to find a husband. On the first floor the sign on the door reads:

Floor 1 - These men Have Jobs.

She is intrigued, but continues to the second floor, where the sign reads:

Floor 2 - These men Have Jobs and Love Kids.

'That's nice,' she thinks, ‘but I want more.'

So she continues upward. The third floor sign reads:

Floor 3 - These men Have Jobs, Love Kids, and are extremely Good Looking.

'Wow,' she thinks, but feels compelled to keep going.

She goes to the fourth floor and the sign reads:

Floor 4 - These men Have Jobs, Love Kids, are Drop-dead Good Looking and Help With Housework.

'Oh, mercy me!' she exclaims, 'I can hardly stand it!'

Still, she goes to the fifth floor and the sign reads:

Floor 5 - These men Have Jobs, Love Kids, are Drop-dead Gorgeous, Help with Housework, and Have a Strong Romantic Streak.

She is so tempted to stay, but she goes to the sixth floor, where the sign reads:

Floor 6 - You are visitor 31,456,012 to this floor. There are no men on this floor. This floor exists solely as proof that women are impossible to please. Thank you for shopping at the Husband Store.

PLEASE NOTE:

To avoid gender bias charges, the store's owner opened a New Wives store just across the street.
The first floor has wives that love sex.

The second floor has wives that love sex, have money and like beer.

The third, fourth, fifth and sixth floors have never EVER been visited.

Kennedy's seizure

Although it is difficult to speculate; the seizure that Sen. Edward Kennedy had yesterday is a very poor prognostic sign when you carry the diagnosis of the type of brain tumor he has.

He reportedly collapsed during the Inaugural luncheon for President Barrack Obama and some of the news media related it to stress and fatigue.

Although both of these do increase the seizure risk, the odds are that his tumor and cancer is progressing.

The average life expectancy for his particular glioblastoma is usually around 6 months from the time of diagnosis. Surgery can offer additional time, but it is very rarely curative.

It is nice that he has lived long enough to witness the historic occasion of the inauguration of the first black President.

They Giveth and They Taketh

There is more bad news from the State Medicaid program as the difficult economic times impact this program.

In an effort to reach a balanced budget, Gov. Daniels asked each state agency to rein in spending for the next fiscal year. Doing its part, the Family and Social Services Administration (FSSA) presented a budget that proposed paying health care providers 95 percent of the fee schedule per claim, beginning July 1, 2009.

It was in the Fall of 2007 that physicians were told the Medicaid reimbursement rates would increase by about 1.5 percent. This was the first increase physicians had since the early 1980’s.

This proposed 5 percent holdback will result in a net decrease of 3.5 percent in July. This will not be acceptable to physicians and many of us will just stop seeing Medicaid patients completely.

“It is unfortunate that the current state of the economy is forcing Medicaid to take the extreme action of a 5 percent holdback,” said Michael Rinebold, ISMA director of Government Relations.

“The process to implement the changes does not require legislation, but it will require administrative rulemaking, which is expected to be completed within six months.”

Jeffrey M. Wells, M.D., director of Office of Medicaid Policy and Planning, hoped the provider rate withhold could be avoided but, said it is critical that the agency plan for the worst. “With the recent revenue forecast showing challenging economic times ahead and with the governor’s commitment to a balanced budget without tax increases or eligibility restrictions, FSSA will need to look at several ways to ensure we continue responsibly managing the program,” he said.

It is very important that the ISMA represents the Indiana physicians and makes it crystal clear that losing doctors out of the Medicaid system will cause more patients to utilize the Emergency Rooms and will actually cost the State agency more money. This is not “Rocket Science” and it is very shortsighted thinking on the legislative side.

It will be very important for physicians and the ISMA to let them know how many physicians they will potentially lose.

The memo regarding this proposal can be read here.

Hawaii's New On-line Service

Hawaii is charting some new territory in Health Care with its new online medical service American Well.

This service is being offered by HMSA, a Blue Cross Blue Shield Association licensee. They announced in June it would be the first commercial health insurer in the U.S. to offer the American Well service to its members.

The member pays a $10 co-pay for the 10-minute maximum online visit and the physician receives $35 fee, with $10 deducted for American Well’s malpractice coverage and administrative costs. Online visits must last at least three minutes in order for the doctor to earn the fee and the patient must be the one to end the call. The encounters can occur on a web camera, over the phone or through a text chat.

The service goes live with more than 120 doctors in Hawaii on January 15 through the state’s largest health insurer, Hawaii Medical Service Association, and while online, physicians will have the patient’s claims history with HMSA on the screen during the e-visit.

Non-HMSA members in Hawaii will pay $45 for an online visit, with doctors still receiving the same $35 fee, but without the claims history available. This may offer physicians and practices a steady revenue stream for small services, such as prescription renewals, routine follow-ups and general health questions, and others which it formerly handled over the phone without compensation.

This would certainly be a way to handle the after hours calls we now take and get zero reimbursement for. Our group is ready to sign up.

Amish Gene Mutation

There has been a recent gene mutation found among the Old Order Amish population that significantly reduces the level of triglycerides in the blood and appears to help prevent cardiovascular disease. This information was released by the researchers at the University of Maryland School of Medicine.

The lead investigator said they found that about 5 percent of the Amish have a gene mutation that speeds up the breakdown of triglycerides. The study results were published in the December 12 issue of Science.

They also looked at calcium deposition in the arteries and found the people with the gene mutation were much less likely to have any calcification.

This information may help with further gene manipulation in the future to help those at risk and may offer new mechanisms for drug research.

A Burglar with Manners

Maybe some of our criminals can take a lesson from this British burglar.

Several days after frightening a 91-year-old woman during a home invasion, this particular, but unnamed, burglar sent an apology note along with a bouquet of flowers to her Halifax home which was about 200 miles north of London.

In the note, the robber explained he believed the residence to be empty when he broke in around 4 a.m. on Oct. 9. He didn’t mean to startle the woman and he ended up leaving empty handed. The police did not take the gesture as a way to get out of the crime and have asked him to come forward with his identity, not just a floral arrangement.

But you have to admit, the gesture was nice.

Increase Medication use in Kids

In another study recently released in the October 31 online Pediatrics, they show the number of US children using medications for chronic illnesses increased between 2002 and 2005
Investigators looked at prescription claims data from 2002 to 2005 for a nationally representative sample of more than 3.5 million children ages 5 to 19.

Antihypertensives, antihyperlipidemics, type 2 antidiabetics, antidepressants, attention-deficit disorder (ADD) and attention-deficit/hyperactivity disorder (ADHD) medications, and asthma-controller therapy were evaluated.

The results showed that the prevalence rate for type 2 antidiabetic agents doubled, with a 166% increase in prevalence among females ages 10 to 14, and a 135% increase among females ages 15 to 19.

Asthma medications (46.5%), ADD and ADHD medications (40.4%), and antihyperlipidemics (15%) all increased in prevalence as well, while antihypertensives and antidepressants increased at a relatively lower rate (1.8%).

The study authors commented the additional research is needed to investigate the possible factors involved in the increase in medication use. They specifically cited factors such as chronic disease risk factors growth, greater awareness and screening, and greater use of early treatment. What they failed to mention was another possibility; overuse and over-diagnosis of some of these conditions.

Certainly the single prevailing factor that contributes to many of these issues is the rising obesity problems in the United States.

Media Influence Study

In a recently released meta-analysis, investigators from the National Institutes of Health, Yale University, and the California Pacific Medical Center examined 173 different studies on the effects of various media and how they impacted children. The media was primarily television, but also included video games, film, music, and computers.

A link can be found here: New Study: Exposure to Media Damages Children's Long-Term Health Common Sense Media

In 80% of the studies, greater media exposure was linked to negative health outcomes for children and adolescents.

Eighty-six percent of 73 studies found a statistically significant relationship between increased exposure to media and obesity risk, while 88% of 24 studies found such a link with tobacco use. Increased media exposure was linked to drug use in 75% of eight studies, alcohol use in 80% of 10 studies, low academic achievement in 65% of 31 studies, sexual behavior in 93% of 14 studies, and ADHD in 69% of 13 studies.

One of the statements made was “The recommendations from the study urge parents to place limits on the amount of media their kids consume, as well to make smart, age-appropriate choices.”

I think this will only work when the adults heed the same advice. Too much media has a detrimental affect on adults as well!

Brain Stimulator

Recently, investigators from the Stanford Epilepsy Center presented the first public results of the brain stimulation that has helped control seizures in epilepsy patients.

The study involved an implantable device that is like a pacemaker. It uses electrical energy to stimulate a part of the brain that helps minimize the seizures.

The exact mechanism of why this works is not known but it is thought to have something to do with disrupting the highly synchronized abnormal electrical activities in the brain during a seizure.

The device consists of a pulse generator that is implanted in the chest and connected to small electrical wires that are tunneled beneath the skin and up the neck to the top of the head. The wires pass through the skull and reach deep into the brain, where they deliver electrical stimulation.

Patients enrolled in the study have had epilepsy for an average of 22 years, and their cases have been so severe that epilepsy medications haven't helped much.
Some of the key highlights from the study include:

• 53 patients using the device in conjunction with epilepsy medications saw a median reduction in seizure frequency of 38 percent at three months


• 60 percent of study participants for whom researchers had long-term data reported a 50 percent or greater reduction in their baseline rate of seizures at the end of the study period—anywhere from one to four years.

Overall, the study showed extremely positive results, but like all others there were some adverse events but none were too serious.

Problems with Resident Work Hours Restrictions

What follows is a reprint of an article by Jane R. Gilsdorf who is a professor of pediatrics. The article describes clearly what the limitiations in resident work hours has done to the training programs.

More physicians are going to be completing their training programs and entering private practices with even less real life experience in managing patients. The quality of care will diminish. You cannot teach experience. The only way it occurs is with actual hands on training no different than other professions.

The difference is that this profession deals many times with life and death decisions.

Introduction

The pediatric infectious diseases (PID) team assembles in the hallway for rounds here at the children's hospital where I have worked for twenty-five years. I'm the attending physician during the next two weeks, and the other team members include the PID clinical fellow, two pediatric residents, a medical student, and two pharmacy students.

"Where's Diana?" I ask. Diana, a second-year pediatric resident, is doing a month-long elective on pediatric infectious diseases. On Monday afternoons and Wednesday mornings she is at her primary care continuity clinic. Today is Tuesday. She should be here.

"She was the night float on hem-onc last night, so she's home now," the PID fellow says, using hospital shorthand for hematology-oncology. "She'll be at her continuity clinic tomorrow morning and then here tomorrow afternoon."

"Well, where's Don?" I ask. Don, a third-year pediatric resident, is also taking an elective with PID this month.

"He had to cover the ICU [intensive care unit] today because of some glitch in the schedule. He'll be here tomorrow morning and then gone to his continuity clinic tomorrow afternoon."

Missing Residents

Both residents working with the pid team are elsewhere today. They aren't available to examine their patients, to learn about new symptoms from the parents, to review the results of the most recent lab and radiographic tests, to review the nursing assessments for the past twenty-four hours, or to make recommendations for ongoing care for their patients. The PID fellow tried to do their work today as well as her own.

Residents like Diana and Don—young physicians learning to be clinical specialists—have long been the mainstay of medical care in teaching hospitals. Because residents traditionally worked in hospitals in the name of receiving education and because altruism is a hallmark of doctors, physicians-in-training have provided a considerable amount of clinical care while working long hours for relatively short pay. What's going on here? Why aren't Diana and Don on PID rounds as they were supposed to be? It's the result of cockamamie resident physician work schedules that look more like Bingo cards than a comprehensive system for providing coordinated medical care or educating future medical specialists. The erratic schedules are the unintended consequences of the new rules on resident work hours.

In 2003 the Accreditation Council for Graduate Medical Education (ACGME), which accredits U.S. medical training programs, instituted rules for resident work hours, sometimes called "the eighty-hour workweek"; the new rules limit residents' duty hours to no more than eighty hours a week. These rules govern the working conditions of the 100,000 young doctors-in-training in teaching hospitals across the United States and were developed both to protect patients from potentially unsafe medical practices by sleep-deprived physicians and to improve working and learning conditions for residents. The work rules, among other stipulations, limit both the number of consecutive days in a week and the number of consecutive hours in a shift that a physician-in-training can work; in addition, the rules require rest periods of at least ten hours between shifts.

Nobody wants procedures or important decisions to be made by exhausted, blurry-eyed, muddle-brained doctors, so the intent was to form medical teams that would work in rotating shifts, thus providing the physicians with adequate time off. As a result, several times a day, responsibility for patient care shifts as it is passed from team member to team member. Although several studies suggest that compliance with the new work rules reduces wandering attention on the part of the residents, might reduce actual or near-miss car accidents involving exhausted residents who've worked extended hours, and appears to reduce serious medical errors in ICUs, other studies are ambiguous about the outcomes of the rule changes. Furthermore, the validity of the methods and analyses in these studies and the generalizability of the results are open to discussion. In short, the total impact of the new rules on physician performance and learning, as well as on patient care and safety, remains largely unknown.


Sprinting Through Care


So we begin our rounds without Diana and Don. Today, like every day, we'll design therapeutic strategies for very sick children who have rare or complicated or difficult-to-treat infections. Many of these children have compromised immune systems caused by an accident of nature or by chemotherapy for cancer or by immunosuppressing drugs to prevent a transplanted organ from being rejected. As we walk through one of the wards, a first-year resident stops me in the hallway.

"Dr. G, could I ask you a question?"

"Sure."

"We have a patient with hypogammaglobulinemia and a protein-losing enteropathy. Should we continue his IVIG and trim-sulfa?" The resident has just described, in these few words, a patient with low antibody levels, most likely because too much protein, including antibodies, is passing into his stools. She's asking if the child should continue to receive intravenous immunoglobulin therapy to replace the antibodies and if the child should continue to receive the antibiotic trimethoprim-sulfamethoxazole.

"Well, that's complicated," I answer. "For starters, how old is the child? Why does he have a protein-losing enteropathy, and how long has he had it?"

The resident shuffles the papers in her hand. "Um, I really don't know him very well. I'm just cross-covering because his primary resident is 'post-call'." Translation: She's filling in for the patient's resident physician who was on duty overnight and, because of resident work hour rules, is unavailable today.

"I can't begin to answer your question without knowing the details," I say. "Why is the patient on the trim-sulfa, anyway?"

"Don't know."

"Will you be calling in our team to consult about this patient?" I ask.

"I don't think so. The senior resident told me to ask you about it."

"Well, I can't make recommendations about stopping treatment until I understand the whole situation. Put in for a consult and we'll figure it all out."

Is she a bad resident for asking me for a recommendation on a patient I don't know? No; like all residents, she has been given responsibility for the care of a very ill patient during the current eight-or ten-or twelve-hour shift, but she didn't take care of him yesterday and probably won't take care of him tomorrow. She doesn't know the full story of this patient's recent illness, doesn't know the long-term plans, and wasn't part of the previous decision making to design the

patient's current treatment. This resident is filling an open shift in the schedule, and her goal is to place a check in the box beside the item on her list that says, "Ask PID about stopping IVIG and TMP-SMX."

Is this a bad hospital? No; stop-gap measures designed to provide physician care to all patients around the clock, seven days a week, are found in every teaching hospital in the United States. By limiting the number of work hours of each resident, however, the new ACGME rules have effectively decreased the hospital's resident physician workforce by 25 percent—in other words, a full quarter of them have gone missing.

The problem is that losing 25 percent of the workforce hasn't been accompanied by hiring additional physicians. As a regulatory agency, the ACGME issues mandates to ensure that young physicians receive excellent clinical training; it usually doesn't approve adding increased numbers of residents to a training program just to plug a hole in a hospital's need for clinicians.
A hospital's inability to increase the number of resident physicians isn't the only barrier to improved staffing—most hospitals can't afford increased numbers of residents anyway. At the same time that the new rules have come into effect, the resources to pay for medical care are vanishing. Medicaid and Medicare payments for health care services are decreasing, and insurance payments are following this lead. Furthermore, more and more patients—forty-seven million currently—have no insurance, which means that they don't pay—because they can't pay—the bill. Although so-called physician extenders (such as physician assistants and nurse practitioners) might take on some of the tasks of the missing physicians-in-training, nursing practice isn't medical practice; even advanced practice nurses or physician assistants haven't had the comprehensive training required to be good doctors. In addition, many physician extenders command salaries similar to those of physicians-in-training yet work only forty hours a week; hiring them as replacements would mean a 100 percent increase in costs.

Keeping An Eye On The Clock


We continue our rounds and enter the staff room, where an intern, seated at a laptop computer, is feverishly keyboarding a progress note that documents the current status and treatment plans of one of his patients.

A senior resident enters. "What are you doing here?" she asks the intern.

"Finishing up my notes."


"You can't do that. You've got to get out of here."


"But, the notes…"


"I'll do them for you. Make a list."


"I also wanted to check the rash on the kid with Kawasaki disease…"


"You can't. You've got to go home."


Apparently the intern in the staff room is up against the limits of the work rules and has been told to leave the hospital. There's no wiggle room. The ACGME requires training programs to report the actual hours spent in the hospital; it leaves it up to the training programs to figure out how to get the work done in the time allotted. If the intern continues on duty beyond the dictates of the rules, our training program might be cited for noncompliance. The penalty for too many citations: probation for the training program or possibly withdrawing the program's ACGME accreditation. A training program on probation or without accreditation has an extremely hard time attracting excellent resident physicians.

We proceed to the next ward. There we meet another resident who, earlier, had submitted a request for a PID consultation.

"Let's talk about the boy admitted last night with the neck mass," I say to her.

"Yeah…tell me what to do with him," she answers.

"Rather than my telling you what to do, let's think it through together so you'll understand how to do work-ups of kids with cervical lymphadenopathy."

"I don't have time for that.Please, Dr. G,just tell me what to do."

Unintended Consequences


Besides ensuring excellent medical treatment for patients, the ACGME work rules were intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians. The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient's response to an intervention; they can't follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In evaluating their training programs, residents often ask for increased autonomy. They realize that in the future they'll be solely responsible for the care of their patients, and they worry that without a certain amount of autonomy during their training, they won't be adequately prepared for independent decision making. Yet with their current here-today-and-gone-tomorrow schedules, they can't be given increased autonomy—they won't be around for the next step or haven't been around for the last step. They don't have the big picture.

The children's hospital where I work contains what I consider the world's most precious treasure: children who are the future of our society. The other great treasure in my hospital is the young physicians of tomorrow who will carry forward our medical values, traditions, and practices. The reason that the doctors at my children's hospital are disappearing or aren't there when they're needed is, simply, inadequate resources to compensate for the restrictions of the new work rules and the resulting workforce reduction.

It's always about the money. In terms of the new ACGME regulations and providing medical care for children, we (meaning our society) can't seem to figure out the money part.Yes,to some extent, we might be able to work"smarter" with new technologies and information systems. Yes, we need to figure out how to streamline communication among the many team members.


Indeed, we need resources to create real teams.

As we consider how to allocate medical and educational dollars, the question becomes, What's more important than healthy children and well-educated physicians? We know the answer: Nothing. But when the next question is, What are we doing to meet the challenge of having enough doctors for enough hours in all of our hospitals, we also know that answer: Nothing.

A Doctor's Response to Health Questions......

Here are the answers to some commonly asked questions:

Q: Should I cut down on meat and eat more fruits and vegetables?
A: You must grasp logistical efficiencies. What does a cow eat? Hay and corn. And what are these? Vegetables. So a steak is nothing more than an efficient mechanism of delivering vegetables to your system. Need grain? Eat chicken. Beef is also a good source of field grass (green leafy vegetable). And a pork chop can give you 100% of your recommended daily allowance of vegetable products.

Q: I've heard that cardiovascular exercise can prolong life; is this true?
A: Your heart is only good for so many beats, and that's it... don't waste them on exercise. Everything wears out eventually. Speeding up your heart will not make you live longer; that's like saying you can extend the life of your car by driving it faster. Want to live longer? Take a nap.

Q: Should I reduce my alcohol intake?
A: No, not at all. Wine is made from fruit. Brandy is distilled wine, that means they take the water out of the fruity bit so you get even more of the goodness that way. Beer is also made out of grain. Bottoms up!

Q: How can I calculate my body/fat ratio?
A: Well, if you have a body and you have fat, your ratio is one to one. If you have two bodies, your ratio is two to one, etc.

Q: What are some of the advantages of participating in a regular exercise program?
A: Can't think of a single one, sorry. My philosophy is: No Pain...Good!

Q: Aren't fried foods bad for you?
A: YOU'RE NOT LISTENING!!! .... Foods are fried these days in vegetable oil.
In fact, they're permeated in it. How could getting more vegetables be bad for you?

Q: Will sit-ups help prevent me from getting a little soft around the middle?
A: Definitely not! When you exercise a muscle, it gets bigger. You should only be doing sit-ups if you want a bigger stomach.

Q: Is chocolate bad for me?
A: Are you crazy? HELLO Cocoa beans! Another vegetable!!! It's the best feel-good food around!
Q: Is swimming good for your figure?
A: If swimming is good for your figure, explain whales to me.

Q: Is getting in-shape important for my lifestyle?
A: Hey! 'Round' is a shape!

Well, I hope this has cleared up any misconceptions you may have had about food and diets.

And remember:

'Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather to skid in sideways - Chardonnay in one hand - chocolate in the other - body thoroughly used up, totally worn out and screaming' WOO HOO, What a Ride'

AND.....

For those of you who watch what you eat, here's the final word on nutrition and health. It's a relief to know the truth after all those conflicting nutritional studies.

1. The Japanese eat very little fat and suffer fewer heart attacks than Americans.

2. The Mexicans eat a lot of fat and suffer fewer heart attacks than Americans.

3. The Chinese drink very little red wine and suffer fewer heart attacks than Americans.

4. The Italians drink a lot of red wine and d suffer fewer heart attacks than Americans.

5. The Germans drink a lot of beers and eat lots of sausages and fats and suffer fewer heart attacks than Americans.

CONCLUSION

Eat and drink what you like. Speaking English is apparently what kills you.

Google Flu Tracker

Google search engines are expanding into the medical field. Google and the Centers for Disease Control and Prevention (CDC) have developed a new online tool that accurately tracks flu trends in every state and officials at the CDC hope the site will serve as an early warning system for flu outbreaks.

This site is free to everyone and uses aggregated search data to estimate flu activity. Google researchers compared flu-related search queries from each state and region and correlated the data with the number of people who actually had flu symptoms and was able to estimate flu activity nearly two weeks ahead of traditional systems.

CDC officials said the information will allow them to alert hospitals, clinics and doctors to stock up on tests and drugs before an outbreak intensifies in their areas.

The web site can be accessed here: Google Flu Trends

Addicted Physicians

Addictions have no socioeconomic boundaries and about 10-12 percent of physicians in our country develop a substance abuse disorder.

The field of addiction medicine has matured greatly in the past 20 years and has progressed from basic science and anecdote to large-scale clinical studies with meaningful outcomes.

In a recent article in the British Medical Journal (BMJ 2008;337:a2038) they published a five-year outcomes study of a large cohort of U.S. physicians treated for substance. Each state has some sort of physician health program to assist with these physicians. The purpose of this study was to determine the effectiveness of these state physician health programs.

It is important to note that these programs do not treat physicians but rather provide assessment and triage into care systems, and then carry out post-treatment monitoring. The ISMA’s Physician Assistance Program functions in this way.

The BMJ study concluded that about three-fourths of U.S. physicians with substance use disorders managed in physician health programs had favorable outcomes at five years. The data suggest that these programs, including the ISMA’s program, operate not only in the interest of the individual physician, but also in the interest of public safety.

The results showed that 95 percent of physicians who completed monitoring in the study were licensed and working as physicians five years later. This clinical data tell us why it is so important to extend a helping hand to our chemically dependent colleagues.

This research is important for physicians to understand who serve on hospital credentialing committees or executive committees as well as to non-medical committee members (administrators and attorneys) who may drift toward other less successful strategies.

There is ample evidence supporting intervention and medical treatment rather than the punitive pathway and anecdotal experience suggests punishment without rehabilitation actually brings opposite results, driving the problem further “underground.”

This not only serves the physician poorly, but also quite possibly decreases patient safety.

Pertussis on the Rise

Some areas in Indiana have seen and increased of pertussis cases more than usual, and health officials are urging physicians to start antibiotic therapy for patients who may have the illness.

Shelbyville schools have informed parents about three cases of the disease, which exposed students and teachers.

Many of the reported cases are in adolescents and adults who are eligible for the Tdap vaccine that gives these individuals a booster against pertussis as well as the tetanus and diphtheria.

The Indiana State Department of Health (ISDH) states we need to do a better job of promoting the use of Tdap in our practices to protect these individuals from contracting pertussis and from spreading it to those at increased risk for complications, such as infants at home or pregnant women.

Last year, a total of 68 cases had been confirmed and as of Oct. 24, 78 cases of pertussis or whooping cough had been reported in Indiana, with an additional 19 cases under investigation.

The symptoms of pertussis typically begin seven to 10 days following exposure and occur in three stages. First, an individual may experience cold-like symptoms, including a runny nose or sneezing. A mild, occasional cough may develop as well.

During the second stage, the cough becomes more severe with bursts of coughing that may cause difficulty catching one’s breath (resulting in a whoop sound) or vomiting following coughing. This stage can last as long as 10 weeks.

Finally, the cough begins to resolve and become less persistent.

The following steps are recommended:

• Patients suspected of having pertussis should remain home from work or school for five days while taking appropriate antibiotics or 21 days if they choose not to take antibiotics.


• Symptomatic close contacts of individuals suspected of having pertussis should be isolated for five days while taking appropriate antibiotics.


• Asymptomatic close contacts should be placed on antibiotic prophylaxis but may remain in school or at work.


• Assess the vaccination status of patients. Children younger than 7 years are eligible for the DTaP vaccine, and persons ages 10 through 64 years are eligible for the one-time Tdap pertussis booster vaccine.

There are lab tests available to aid in the diagnosis and all suspected cases of pertussis should be reported immediately to the local health department

Once again, appropriate immunizations prevent this type of disease.

Red Flags

Many physicians and hospitals received a reprieve and probably didn’t even know it. In October, the Federal Trade Commission delayed enforcement from Nov. 1, 2008 to May 1, 2009 of its so-called “red flags” rules, which require creditors to establish a written program for combating identity theft.

The problem occurred because the FTC has defined most physicians and hospitals as “creditors,” which immediately drew criticism from the American Medical Association and other medical groups, who argue that the FTC is too broadly defining the term.

The red flags rules are based on legislation that defines a creditor as “any person who grants the right to defer payments” and therefore this would apply to physicians and hospitals who accept payment, either in part or in full, at a time after they provide medical services to patients.

This would be a great reason for physicians and hospitals to immediately begin demanding full payment at the time of service and make patients deal with the insurance hassles.

This red flags requirement makes the companies create a written program listing warning signs for ID theft, how they’ll detect those threats, and how they’ll respond.

Hospitals and physicians would have to define a program to screen for the following types of activities and manage the program accordingly:

· Records showing medical treatment that is inconsistent with a patient’s history
· Suspicious documents, such as a forged insurance card
· A patient who has an insurance number but no card or documentation
· Unusual billing patterns

The FTC did decide to delay the enforcement of the red flags rules because there was “lots of confusion” about the rules among “entities not accustomed to being regulated by the FTC”
If the rule takes effect, the penalties can be a fine to violators of up to $2,500 per offense.

The AMA sent a letter to the FTC and they along with 26 other medical organizations said they “strongly disagreed” with the FTC’s decision to define physicians as creditors.

There has reportedly been no response to the AMA’s statements.

Most physicians and relatively few hospitals are aware of this rule but the ones that are stated it would cost them more than $10,000 to comply.

Here is another example of over-regulation that is crushing our health care delivery system and creating much more needed expense.

The New Year

I hope everyone has a safe, happy and prosperous New Year and that 2009 treats each of you very well!