Another day, Another beating up of specialists by the NY Times

[DrBodacious]

All irrelevant in a truly free market, in which prices are determined only by supply and demand - nothing else. How do you price "invasiveness?" With what do you measure "invasiveness?" Why does this metric measure "invasiveness?" What is the price for each unit of such a metric? And how do you know this or test this?
I understand the argument you're trying to make, and realize the superficial logic that it may make to some people. Unfortunately, it is simply a non-sequitur in a free market.

To chime in on the discussion of how current procedure reimbursements are determined: it is a process that is fairly well described, http://en.m.wikipedia.org/wiki/Resource-based_relative_value_scale

---

Members don't see this ad.

 

[Schland]

No one expects you to divine anything. However, I do expect a medical student to understand that things aren't as black-and-white and the solution isn't as easy as they think it is and to understand that somethings have a lot more nuance and depth that aren't initially reported in journal articles that aren't "scientific". That's not something that has to be stated directly in order to understand.

Think that malpractice doesn't have as much of an effect? Ask this Emergency Medicine physician who left Massachusetts and now will be ordering every lab test, imaging, procedure in the book, including a heart biopsy, for every young man that comes in with fever and cough. Congrats, now at least we can tell them they can be assured they don't have viral myocarditis along with their huge medical bill.

http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

This article makes me sad about healthcare today. IMO a doctor shouldn't be found guilty unless there is obvious abuse/ neglect or they miss something that the majority of other doctors in the field who have not have/ they didn't follow the standards of practice. And if patients truly don't feel the doctor treated them right they always have a right to a second opinion. (On the flip side I did an internship on a stroke/ brain injury unit and saw both stroke and brain tumor patients who had much worse outcomes because they first time they saw a doctor for a headache they got sent home.. eventually things got worse a scan got done and the diagnosis was made. I know it's a hard thing because the majority of headaches aren't tumors and you aren't going to order a CT/ MRI for everyone that walks in the door with them.)

But back to the original article putting a stab at PTs aka "the person in scrubs." Please, I'd rather be "the person with the walker" defines me better from the millions of others in scrubs. How would a patient feel if they had surgery, had no PT come to make sure they can't get up and about safely, fall, and injure themselves. The hospital would be sued because no professional came in to check on that. They can't have it both ways. Patients are typically in more pain when they get up for the first time than they would expect. And, you know, if it's a surgery where something like the glut max is cut in half, that leg may just be a little weaker, but who am I to say anything I just want to bill unnecessary charges obviously. If the patient proves themselves to be capable and safe, the PT signs off the case and lets nursing know what they saw.

 

[bronx43]

To chime in on the discussion of how current procedure reimbursements are determined: it is a process that is fairly well described, http://en.m.wikipedia.org/wiki/Resource-based_relative_value_scale

Did you even read the actual discussion? I don't need a lecture on RVUs. My position is that price setting outside of a free market is invalid at its core.

 

[DrBodacious]

Did you even read the actual discussion? I don't need a lecture on RVUs. My position is that price setting outside of a free market is invalid at its core.

I am referring to the parts of your discussion where you demonstrate your lack of knowledge or misunderstanding about the how the current fee schedules have been developed.

Malpractice doesn't come close to covering the reimbursement disparity, and "invasive-ness" cannot be a pricing mechanism. There is no logical rationalization for reimbursement schedules. It is in itself a contradiction to espouse the health care payment system while supporting a free market.

How do you price "invasiveness?" With what do you measure "invasiveness?" Why does this metric measure "invasiveness?" What is the price for each unit of such a metric? And how do you know this or test this?
I understand the argument you're trying to make, and realize the superficial logic that it may make to some people. Unfortunately, it is simply a non-sequitur in a free market.

"Invasiveness" is not a term used in the RVU process, but a more "invasive" procedure would translate to higher levels of physician work, practice expense and malpractice expense, which are the three main components that the Relative Value Update Committee (RUC) examines in assigning an RVU to a procedure. Malpractice expense is directly figured in to the RVU system.

Obviously RVUs -> medicare fee schedule -> most other insurance fee schedules. I am not arguing that the system get the prices correct, but it tries to settle the fact that anyone you ask would give you a different opinion on what the "correct" fee schedule should be.

 

[AFMD]

No one expects you to divine anything. However, I do expect a medical student to understand that things aren't as black-and-white and the solution isn't as easy as they think it is and to understand that somethings have a lot more nuance and depth that aren't initially reported in journal articles that aren't "scientific". That's not something that has to be stated directly in order to understand.

I guess inferring your entire argument from nothing is beyond my capacity as a lowly "medical student".

Think that malpractice doesn't have as much of an effect?

No, I do think it has an effect.

To chime in on the discussion of how current procedure reimbursements are determined: it is a process that is fairly well described, http://en.m.wikipedia.org/wiki/Resource-based_relative_value_scale

I'd never actually read the Wikipedia article on this. It's a really nice and concise explanation.

 

[AFMD]

LOL, I was going to post some big reply but I'll save most of my breath. Suffice it to say that:

1) Based on the article you posted earlier which you are obviously convinced is good "evidence", you're going to make quite the impression at your Journal Club in residency.

I never posted the article. I just wanted to know why Dermviser disagreed and dismissed the whole article. Why is it such a big deal that I point out that Dermviser didn't explain anything? All I want is an explanation. But then he just replies I should already know.

2) You're a medical student, so actually I'm not too worried because you're smart and you'll learn. In much the same way as so many of my classmates started med school by saying, "medicine is all about altruism and I'd be a third world primary care doctor for free", then finished by matching into ENT or Derm (and in one case Integrated Plastics), you'll learn. You haven't practiced medicine yet, and I 100% guarantee that when you get to residency and start practicing, you're going to go "oh crap, over half of what I do is completely CYA. Those guys weren't kidding!" When that happens come back here and post, and we'll all laugh along with you and give you a hearty internet slap on the back because, hey, we've all been the naive med student at one point, and it's just part of the learning process.

I completely realize this, and I'm fine with it. I just don't understand why a complete lack of explanation in someone else's post is my fault. If a post is only understandable by an experience physician, then you going to leave me behind. But, I'm still going to challenge it if it doesn't make any sense to me. That's all I got man.

 

[DermViser]

LOL, I was going to post some big reply but I'll save most of my breath. Suffice it to say that:

1) Based on the article you posted earlier which you are obviously convinced is good "evidence", you're going to make quite the impression at your Journal Club in residency.

2) You're a medical student, so actually I'm not too worried because you're smart and you'll learn. In much the same way as so many of my classmates started med school by saying, "medicine is all about altruism and I'd be a third world primary care doctor for free", then finished by matching into ENT or Derm (and in one case Integrated Plastics), you'll learn. You haven't practiced medicine yet, and I 100% guarantee that when you get to residency and start practicing, you're going to go "oh crap, over half of what I do is completely CYA. Those guys weren't kidding!" When that happens come back here and post, and we'll all laugh along with you and give you a hearty internet slap on the back because, hey, we've all been the naive med student at one point, and it's just part of the learning process.

I like how his response to my quote (which he completely chopped up and parsed) he leaves out the link I put of an EM physician who lost a malpractice case for 5 million dollars for nothing he could have done.

 

[DermViser]

No, I do think it has an effect.

Thanks for parsing my quote. I guess you didn't take the time read the article about the EM Physician who lost a lawsuit for 5 million dollars on a condition he could have done nothing about. That case is the best example of how malpractice will affect what things are ordered. You can ignore them all you want, but they exist.

 

[AFMD]

Thanks for parsing my quote. I guess you didn't take the time read the article about the EM Physician who lost a lawsuit for 5 million dollars on a condition he could have done nothing about. That case is the best example of how malpractice will affect what things are ordered. You can ignore them all you want, but they exist.

What are you talking about? My first post in this thread was about waste spending, and as soon as you mentioned malpractice I quickly agreed. I read the article, I agreed with you, and I challenged an unexplained opinion you posted... that's it. It's all in print, read the thread man.

 

[TooMuchResearch]

Thanks for parsing my quote. I guess you didn't take the time read the article about the EM Physician who lost a lawsuit for 5 million dollars on a condition he could have done nothing about. That case is the best example of how malpractice will affect what things are ordered. You can ignore them all you want, but they exist.

Modern medicine: "My patient in room 7 has bronchitis. No testing or treatment is indicated, so I will only need several tests before treating him."

 

[bronx43]

Thanks for parsing my quote. I guess you didn't take the time read the article about the EM Physician who lost a lawsuit for 5 million dollars on a condition he could have done nothing about. That case is the best example of how malpractice will affect what things are ordered. You can ignore them all you want, but they exist.

Not that this is pertinent to the point at hand, but it's entirely false that there was nothing that could have been done for this patient. I'm not saying that the diagnosis should have been made based on the young man's symptoms, but having viral myocarditis isn't a "go home and hope you don't die" diagnosis. While it's true that there is no definitive therapy for it, supportive care can mean life or death. Depending on the degree of myocardial inflammation and cardiomyopathy, they should be admitted for close observation (which this patient would have been), and should they go into fulminant heart failure, they would be placed on inotropes, and be transferred to a tertiary care center for consideration of advanced therapies (LVAD) or heart transplant. In fact, I had two cases of viral myocarditis in patients under the age of 40 on our CHF service several months ago. Both were on inotropes for weeks- one eventually improved and the other had to have a VAD.
All in all, it's a sad case and no one here was to blame, but if the physician was a bit more vigilante about the chest pain (depending on the degree of pain), he MAY have done an ECG, and MAY have caught some abnormality. Again, not his fault given the situation...

 

[DermViser]

Not that this is pertinent to the point at hand, but it's entirely false that there was nothing that could have been done for this patient. I'm not saying that the diagnosis should have been made based on the young man's symptoms, but having viral myocarditis isn't a "go home and die" diagnosis. Depending on the degree of myocardial inflammation and cardiomyopathy, they should be admitted for close observation (which this patient would have been), and should they go into fulminant heart failure, they would be placed on inotropes, and be transferred to a tertiary care center for consideration of advanced therapies (LVAD) or heart transplant. In fact, I had two cases of viral myocarditis in patients under the age of 40 on our CHF service several months ago. Both were on inotropes for weeks- one eventually improved and the other had to have a VAD.
All in all, it's a sad case and no one here was to blame, but if the physician was a bit more vigilante about the chest pain (depending on the degree of pain), he MAY have done an ECG, and MAY have caught some abnormality. Again, not his fault given the situation...

Right so now anyone who has the non-specific symptoms the patient, we'll just automatically straight admit them or put them on obs with the "million dollar" workup. So much for trying to lower costs of healthcare. The patient in question was a young person.

 

[bronx43]

Right so now anyone who has the non-specific symptoms the patient, we'll just automatically straight admit them or put them on obs with the "million dollar" workup. So much for trying to lower costs of healthcare. The patient in question was a young person.

Except, I didn't say that, did I? I said it wasn't wrong for the EM physician to send the kid home. What I'm saying is if the EM physician did an ECG (assuming it shows nothing), he may have won the suit. Or he may have seen something, and proceeded with more testing. Actually, on second thought, he's an EM doc, which means he wouldn't have caught anything that wasn't an obvious STEMI...

 

[DermViser]

Except, I didn't say that, did I? I said it wasn't wrong for the EM physician to send the kid home. What I'm saying is if the EM physician did an ECG (assuming it shows nothing), he may have won the suit. Or he may have seen something, and proceeded with more testing. Actually, on second thought, he's an EM doc, which means he wouldn't have caught anything that wasn't an obvious STEMI...

Or he could have ordered the EKG - the EKG would show any findings that are specific to viral myocarditis and he would have sent her home. The only definitive way to diagnose viral myocarditis is muscle biopsy.

 

[bronx43]

Or he could have ordered the EKG - the EKG would show any findings that are specific to viral myocarditis and he would have sent her home. The only definitive way to diagnose viral myocarditis is muscle biopsy.

The ECG may show nothing, you're right. But, it also MAY show something. You may find PR depresisons, or diffuse ST elevations consistent with pericardial inflammation. You may find QRS or QT changes, or evidence of nodal involvement depending on the sites of inflammation. Hell, you may even find subtle hints of electrical alternans if there was a pericardial effusion. All those things would have prompted him to get more studies which may have ended up saving the kid's life. Again, read this: I don't think he was in the wrong to forgo the ECG given the clinical context. But, he would have won the suit if he got the ECG...

 

[DermViser]

The ECG may show nothing, you're right. But, it also MAY show something. You may find PR depresisons, or diffuse ST elevations consistent with pericardial inflammation. You may find QRS or QT changes, or evidence of nodal involvement depending on the sites of inflammation. Hell, you may even find subtle hints of electrical alternans if there was a pericardial effusion. All those things would have prompted him to get more studies which may have ended up saving the kid's life. Again, read this: I don't think he was in the wrong to forgo the ECG given the clinical context. But, he would have won the suit if he got the ECG...

There are NO SPECIFIC findings that would point to viral myocarditis. He would not have won his lawsuit by sending the patient home after ordering the EKG, reading it, and seeing nothing there. Ordering an EKG would NOT have saved him from losing the lawsuit.

Read the blog post on KevinMD: http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

 

[bronx43]

There are NO SPECIFIC findings that would point to viral myocarditis. He would not have won his lawsuit by sending the patient home after ordering the EKG, reading it, and seeing nothing there. Ordering an EKG would NOT have saved him from losing the lawsuit.

Read the blog post on KevinMD: http://www.kevinmd.com/blog/2014/03/doctors-practice-cover-ass-medicine.html

Wtf, have you even practiced clinical medicine before? Obviously, there are no specific ECG findings in viral myocarditis, just like there are no specific ECG findings in the majority of heart conditions - treatable or otherwise. But that doesn't mean that viral myocarditis is un-diagnosable or that ECGs are useless in this clinical scenario. The fact that there may be indirect ECG evidence of myocardial and/or pericardial inflammation means that an ECG MAY have HELPED diagnose the condition, which may have saved the patient's life. In medicine, we don't forgo studies just because there are no SPECIFIC findings for whatever diagnosis we suspect. We obtain studies when a study MAY show direct or indirect evidence to support one diagnosis over another.
Look, I was just making a conjecture that he may have won the lawsuit. Maybe he wouldn't. But I would be hard pressed to imagine a well constructed argument on the plaintiff's end had the doc performed a ECG.

 

[DermViser]

Wtf, have you even practiced clinical medicine before? Obviously, there are no specific ECG findings in viral myocarditis, just like there are no specific ECG findings in the majority of heart conditions - treatable or otherwise. But that doesn't mean that viral myocarditis is un-diagnosable or that ECGs are useless in this clinical scenario. The fact that there may be indirect ECG evidence of myocardial and/or pericardial inflammation means that an ECG MAY have HELPED diagnose the condition, which may have saved the patient's life. In medicine, we don't forgo studies just because there are no SPECIFIC findings for whatever diagnosis we suspect. We obtain studies when a study MAY show direct or indirect evidence to support one diagnosis over another.
Look, I was just making a conjecture that he may have won the lawsuit. Maybe he wouldn't. But I would be hard pressed to imagine a well constructed argument on the plaintiff's end had the doc performed a ECG.

You don't see what excuse a plaintiff's attorney would have come up with if the defendant had ordered an EKG - saw nothing concerning and sent them home? Really? They would have just hired an expert witness to argue the opposite.

 

[bronx43]

You don't see what excuse a plaintiff's attorney would have come up with if the defendant had ordered an EKG - saw nothing concerning and sent them home? Really? They would have just hired an expert witness to argue the opposite.

It would be much much harder (not impossible) to lose the trial if he gotten the ECG and it was normal. From reading the case, it seems to me like the ED doc lost the case because the patient was documented to have chest pain and an ECG was not performed. That, coupled with the fact that the ECG may have shown evidence of myocardial inflammation, is what the jury heard. It is not a far stretch for the plaintiff to pin that one the ED doc, as opposed to not performing... say an echo, which would naturally be the next diagnostic step. Again, not impossible, but I think it would have been much more difficult...

 

[Psai]

Wtf, have you even practiced clinical medicine before? Obviously, there are no specific ECG findings in viral myocarditis, just like there are no specific ECG findings in the majority of heart conditions - treatable or otherwise. But that doesn't mean that viral myocarditis is un-diagnosable or that ECGs are useless in this clinical scenario. The fact that there may be indirect ECG evidence of myocardial and/or pericardial inflammation means that an ECG MAY have HELPED diagnose the condition, which may have saved the patient's life. In medicine, we don't forgo studies just because there are no SPECIFIC findings for whatever diagnosis we suspect. We obtain studies when a study MAY show direct or indirect evidence to support one diagnosis over another.
Look, I was just making a conjecture that he may have won the lawsuit. Maybe he wouldn't. But I would be hard pressed to imagine a well constructed argument on the plaintiff's end had the doc performed a ECG.

You do know that the only treatment is supportive right? Or a heart transplant because there are a lot of those lying around. Either way, kid would have died and it was a bogus lawsuit

 

[bronx43]

You do know that the only treatment is supportive right? Or a heart transplant because there are a lot of those lying around. Either way, kid would have died and it was a bogus lawsuit

Read the actual discussion before you butt in, kid. And no, the pt would not have died for sure. And LOL if you think that supportive care = dead pt, especially when it comes to viral myocarditis.

 

[FIREitUP]

You don't see what excuse a plaintiff's attorney would have come up with if the defendant had ordered an EKG - saw nothing concerning and sent them home? Really? They would have just hired an expert witness to argue the opposite.

I think much of what caused the verdict to go the way it did was that the prosecution probably portrayed the doctor as not caring and dismissive of this patients symptoms while he was essentially dying. I'm sure argued that this POS doctor couldn't even take the time to go through the motions with a dying patient, clearly he doesn't care about his patients; he deserves to pay.

 

[DermViser]

I think much of what caused the verdict to go the way it did was that the prosecution probably portrayed the doctor as not caring and dismissive of this patients symptoms while he was essentially dying. I'm sure argued that this POS doctor couldn't even take the time to go through the motions with a dying patient, clearly he doesn't care about his patients; he deserves to pay.

Any physician can be portrayed as uncaring, dismissive, etc. by an attorney, bc patient notes in the medical record can not convey demeanor, regardless of what actions the physician took or how caring the physician actually was.

 

[Psai]

Read the actual discussion before you butt in, kid. And no, the pt would not have died for sure. And LOL if you think that supportive care = dead pt, especially when it comes to viral myocarditis.

Uh no doctor, I'm saying that an ekg wouldn't have changed the outcome even if it did help make the proper diagnosis which is a very unlikely proposition in the first place. How would it have changed your management? You think you would have saved his life? Lol

 

[VisionaryTics]

Uh no doctor, I'm saying that an ekg wouldn't have changed the outcome even if it did help make the proper diagnosis which is a very unlikely proposition in the first place. How would it have changed your management? You think you would have saved his life? Lol

Supportive care does not mean hospice.

Yes, if you make the diagnosis of viral myocarditis, you can do things like put them in a cardiac ICU, put them on telemetry so you can respond to arrhythmias, augment their cardiac output with inotropes. You can even put them on ECMO to get them through the worst of it.

Am I taking crazy pills?

How bout this: the treatment for influenza is supportive (tamiflu does nothing). Does that mean that every person with respiratory failure from H1N1 dies and it doesn't matter if you provide them supportive care or not?

If someone comes in with a viral syndrome and you get an EKG that shows changes, you don't think that would change your management?

Note, I am not arguing that this doc should've gotten an EKG. I wasn't there and I don't know what the patient said. It's hard to make that judgement from this position.

 

[bronx43]

Uh no doctor, I'm saying that an ekg wouldn't have changed the outcome even if it did help make the proper diagnosis which is a very unlikely proposition in the first place. How would it have changed your management? You think you would have saved his life? Lol

Lol, what are you... like a MS2? Maybe MS3... I hope for your sake you're not a MS4, cuz I'd be embarrassed if any fourth year said s*** this stupid.

I already said this in a post a couple above yours if you actually bother to read the discussion before butting in like a ******. If you found any abnormalities on the ECG (I already listed some of the possible changes), you would then proceed with further testing - or at least get cardiology involved. This patient would likely have been admitted, and an echo would likely have shown systolic dysfunction at this point, and depending his end organ perfusion and volume status, could have been placed on a myriad of inotropes, vasodilators, and diuretics in the CCU. Hell, the two patients I was referring to earlier were sitting in the CCU for weeks with swans sticking out of their necks, while on a combination of dobutamine, milrinone, lasix, and a couple of nipride challenges. Most of these people actually get better by themselves, and one did. The other case, unfortunately, had to get a LVAD as a bridge to transplant. And yes, even ECMO has been used on these people as a bridge to recovery or transplantation.

 

[bronx43]

Am I taking crazy pills?

Lol, I know bro. I don't know what they're teaching these kids in med school nowadays.

 

[Psai]

**** i got schooled lol
nice work team