Friday, December 28, 2007


Practicing in a teaching hospital has its privileges. The latest technology is readily available. There is always a willing, even eager helper. As a general rule there is a collegial relationship between the attending staff (physicians who teach the residents) resulting in the liberal use of the "curb side consult", several physicians offering thoughts on the diagnosis and treatment of difficult cases. This results in a high level of competent care for the patients.

There are also a few drawbacks. One is the constant testing. My kids frequently remark that they will be glad when they are no longer tested. School, I know, seems like a journey from one exam to another, but life is a series of tests too. One of the draw backs of constantly working in a training setting is that every patient encounter, is a proctored examination. Let me illustrate.

As a second year resident it became my job to supervise one of the interns who was so book smart it was frightening. Adam would answer questions with direct quotes from textbooks. I suspect that his memory was photographic. Like most interns Adam lacked judgement.

One Saturday when we were on the labor and delivery unit together, I sent Adam back to the delivery room with one of our most arrogant attendings. There were two ways to preform every procedure, Dr. Jones' way and the wrong way. This appeared to be a routine laboring patient about to delivery her second baby. Adam had been on the obstetrical service only a week but I thought surely he has seen Dr. Jones do another delivery. Besides, all he had to do was help drape the patient, pass instruments to the attending physician and look attentive.

Once the baby's anterior shoulder was out, Dr. Jones always requested the nurse to push 10 units of pitocin in the IV line. Instead of questioning this practice prior to the delivery, it was after the fact when Adam said, "Gee, Dr. Jones, I thought you weren't suppose to do that because you might trap an undiagnosed twin?" Please try to understand that this occurred more than twenty five years ago when there was no such thing as routine sonography.

"Dr. Parker," Dr. Jones replied to Adam, "Any obstetrician worth his salt would know if there were twins by now!" As he was speaking Dr. Jones placed his hand on the patients abdomen and palpated the large mass that was indeed, the second twin.

A few expletives, some nitrous oxide, and minutes later holding a healthy second twin we had all learned something. The process for stopping a very strong contraction and delivering a second twin by breech extraction was etched in my memory. Adam was beginning to process the need for questioning in a less accusing manner before someone above him took action. And Dr. Jones. Well, in the next two and a half years, I never saw him push pitocin prior to the delivery of the placenta again.
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Thursday, December 27, 2007

Health Care 101

News about health care costs soaring is common place. Not infrequently I hear physicians complain about reimbursement, specifically what insurance companies pay physicians for their services.

There are two sides to every coin and the issue of health care costs is no different. I recently heard a patient complaining about the cost of his angioplasty. An angioplasty is a very technical procedure where a cardiologist removes the blockage in one or more coronary arteries that supply blood to the heart muscle. "Why, I could have purchased two jet skis for what this procedure cost." Keeping my thoughts to myself I mused that if he had purchased the jet skis instead of having the angioplasty he could have had a heart attack on the lake.

The other side of the coin is the fact that insurance companies, large hospital and physician groups along with equipment and drug manufacturing companies are making unconscionable profits. I learned how to spell "unconscionable" when I wrote a letter to a company about their product. On the market for years, this product had been sold to physicians for $30 for a 10 dosage vial. That is three dollars a dose. When the medication received FDA approval for a new, more widely needed indication the company began to sell it in a single dose vial for a price of $60 each. I guess I should also thank this company for allowing me to brush up on my math skills. It took me a few minutes to calculate that this was 5000% increase in their profit.

Health care cost inflate the cost of most of the goods and services we buy as employers are forced charge more so that they can afford to pay more for health insurance premiums. You are paying for someone's health care every time you purchase a car, visit your accountant or bring home a bag of groceries. As an intern I was told that health care cost could not reach 12% of our gross national product. That was 26 years ago and today health care represents almost 25% of our GNP.

I don't have an answer to this problem. This blog has been sitting in my list of posts for almost six months because I disdain a complainer who cannot offer constructive solutions. I am very unpopular with my colleagues because I don't believe the solution is to pay doctors more money. Instead the solutions to these problems lie with all those involved, physicians, hospitals, and drug companies returning to the business of caring for patients instead of making a business of patient care.
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