Inpatient primary care medicine

I just finished two weeks as attending on our inpatient service, which was notable to me for a couple of recurring themes.

1. I'm getting old. My residents started theophylline on a patient with asthma and not one had ever used it before.

2. If I could get paid a fraction of the hospital costs I could save by providing patients with prescription medicine upon dischargeI 'd be a happy man. We admitted two patient who were recently discharged, only to fail outpatient life because they couldn't afford the medicines that had been prescribed during their previous admissions for asthma and hypertension, respectively.

3. The admission/discharge pace is frantic, with admitted patients rushed from one test to another to shorten their stay. Except of course on the weekends when the cost of staffing radiology for non-emergent cases doesn't make sense. I suppose not everything changes.

4. Scut has changed. In my residency we plated our own strep cultures (and incubated them), ran our own sed rates, spun our own hematocrits, etc. Scut these days is entering orders into a computer, text messaging by computer, checking email at the computer, etc. Lab scut is notable for what CAN'T be done. Indeed, there's not a microscope or lab on the floors at our two main hospitals. God forbid a resident would have to do a gram stain or wright's stain.

Did that sound as crotchety as it reads?

Why doctor's appointments are like airplane seats

My practice has struggled to balance patient demand for appointments with availability. I've done a lot of traveling lately so have had reason to consider the way that airlines market airline seats, carefully balancing my preferences and willingness to pay against the value in their various seats.

Mid-day flights cost more than early morning flights. Exit row seats cost more than other seats (at least on Northwest.) Frequent fliers get more and earlier choice in seats than non frequent fliers. Want to change flights? That'll be $ please.

Visiting the doctor is at least as expensive as a Southwest roundtrip, and often costs as much as a first class British Airways flat-bed to London. Flyers show up an hour or two early for their trip,queue on command, and print their boarding passes at home.

My QI mavens constantly use the airline quality programs as an example of how medicine should reduce errors. Should we also adopt the pricing and seat controls that airlines use?

Some offices already shunt frequent no-show patients to a special 'alternative probationary' schedule. Isn't this a reverse frequent flier program? Concierge practices charge thousands of dollars to ensure an experience that most of us aspire to provide to our patients anyway. Isn't that a form of 'first class'? Patients in many systems can make appointments online, but I don't know of any that show doctor availability to allow patients a choice of slot. Don't you think my patients would want to know if they're the last slot in a 17 patient session (like yesterday afternoon) vs. first in a 12 patient session (like this morning)? Don't you think they'd pay different for it?

Of course payment is the kicker. We are contracturally forbidden from charging different amounts for the same service to different patients. We are also in the unusual circumstance of not knowing in advance what service will be required before we see a patient. My office visits are one kitchen renovation after another, with the same "Well I didn't know I'd find rotten joists when I agreed to retile your wall" conversations with patients.

Would you fly if you didn't know the fare, didn't know how long it would take to get there, and had no basis to judge the experience of the flight crew or seat comfort on the airplane?

We ask our patients to do that every day.

P4P in primary care

Family Practice Management has an update article on pay for performance in their July/August 2006 issue, including some interesting statistics and graphs on the rise of P4P programs in primary vs. specialty care and among public and private insurers. There's also a nice checklist for docs to consider before signing up for their local P4P.

I've written before on why performance measures don't work well in primary care; attempts to focus on individual disease markers in patients with multiple comorbid conditions is a byproduct of specialist "disease oriented" rather than "patient oriented" care. The result of this thinking is P4P programs that promote physician behaviors that detract from the demonstrably valuable task of balancing complex competing co-morbidities to achieve improved outcomes. Want more? See Barbara Starfield's editorial in Annals. This unending focus on disease rather than patient is one of the greatest failures of US healthcare.

The New York Times has written about P4P. It's also all over the blogosphere:

Retired doc's thoughts: To see what P4P is really all about, look at the Seattle Blue Shield experience

Roy Poses, a decision analysis maven and fellow generalist: Health Care Renewal: Implementing P4P in the Real World: the Case of Regence BlueShield

KevinMD's thoughts

And even some specialists are aggravated by P4P: Aggravated DocSurg: A(nathe)MA, part the second

Bayes' Theorem in the attention economy

Nothing like lecturing in the fourth hour of a five hour conference morning on Bayes' theorem in the guise of screening for coronary artery disease to a room of bottom line learners. I've put the pdf of my keynote presentation here. The 2002 ACC guidelines for exercise testing mentioned in the talk are here. My proudest accomplishment in preparing this talk was finally finding a still of Sigourney Weaver floating over Bill Murray from the movie Ghostbusters to illustrate the concept of guidelines. : )

Presentations 101

I'm a medical school professor, so I give and sit through many lectures. Despite 20 years of trying I still can't get them right, but I'm trying. These three sites might help you with your presentations - they've helped me.

Presentation Zen is my latest favorite. Less is more. Make sure to visit the popular posts and presentaiton tips on the links bar.

Guy Kawasaki describes his 10/20/30 rule, which I've never been able to achieve. While he makes reference to venture capital pitches, the rule is applicable to nearly any stand and deliver presentation, especially if you're projecting something. I had a chance to meet Guy at a Lexington, KY computer show back in the 1990's (pre-internet.) I'll never forget that he used a slide carousel and not a computer LCD projector. At the beginning of his talk he noted that he didn't trust computers with something so important, that he was suspicious of slides too (he had overhead transparancies just in case), and that he'd be just as happy giving his presentation with no visuals at all. In that brief encounter he gave me permission to hate technology for it's shortcomings while still loving it for it's promise.

Lastly is Ian Parker's Absolute Powerpoint piece in the May 28, 2001 New Yorker (I link to a web based text version) that should be required reading for all powerpoint users.

Gordon's Notes: All the vulnerable people: eFraud, aging and special needs

John Faughnan is a family doc who I've been acquainted with since the late 1980's via our common interst in tech. He has the chops, which is why I follow his blog. He's one of my tier one mavens for things medicine and tech.

His take on spam and reputation managment in these days of HIPPA and privacy concerns is more pertinent than anything I've read in the medical journals.

We're going to have to evolve new systems of defense, trust relationships, identity management and reputation management. Developing these systems will be a major social challenge over the next few decades. In the meantime, encourage your parents, and your vulnerable family members, to consult about their financial decisions. From: Gordon's Notes: All the vulnerable people: eFraud, aging and special needs

Future of Family Medicine extended

I've put a pdf of the Keynote presentation that I gave yesterday at our grand rounds on my file sharing page (download it here - 2.5MB.) It's a long way from my original resident conference I presented in 1988, but in many respects the themes are remarkably similar.

Addendum:
I realized that many links I visited in the talk aren't in the slides. Why would they be? Slides are, after all, so very 1995 : )

Here they are, plus a few extras as your reward for visiting:

A mashup for locating doctors in berkeley.

Ratings of doctors. Not quite digg or slashdot, but the rival doctor shopping networks are fighting it out as you read this.

Another doctor mashup. Want a real 'monetizer' for web sites? Get health system marketing dollars pointed at these mashups, buying preferential placement for their docs and hospitals. Did I say that out loud?

Penn's patient blog site for checking on inpatients

Rob Centor's blog - president of SGIM, faculty at UAB

One of many examples of a personal health record.

An example of a virtual conference that I recently 'attended'. Why doesn't STFM or AAFP do this in addition to their 'regular' conference? Much of the networking value (though not all) without the travel costs.

If you know about 'flash mobs' then you won't be surprised that others are holding what amounts to 'flash conferences'. The prototype is here. This is another idea that medicine needs to adopt. It's certainly more convenient (for me) than the bulletin board next to the registration desk with handwritten notes on it for whomever happens to stop by.

One of many social networking sites that our applicants use to discuss the interviewing process. Yes, I'm reading you!

Graphical browsing - enter a website and see what's connected to it and what it connects to. The underlying concept and code is used by many sites as one example of 'conceptual mapping'. See here for other examples to numerous to list.

The point to this site isn't the story, it's the "big picture" link that allows graphical browsing of the related stories. Let the entire page load then click the 'Big Picture' link in the red bar on the right of the page. Any news story you visit on cnet news can be browsed the same way.

Like graphical browsing? See here and here for more examples. Now imagine this technology used to visualize medical concepts. We're getting close but aren't quite there yet. The Krafty Librarian post from last month talks about this.

Drug Quilt is an example applied to the drug industry. It certainly makes it easier for me to see the relative relationships between companies and products.