Provider Certification — proving competance

fltsimDoctors could learn a lot from pilots.  Flight simulators have revolutionized commercial aviation so pilots can train without endangering passengers.  Patient-care simulators do the same for doctors yet doctors fight the idea.  See the article in the Wall Street Journal 7/21/14 by Melinda Beck “Doctors Upset Over Skill Reviews.”

There are cognitive skills and procedural skills; both are amenable to testing and training.  The current buzz words are “maintenance of certification” or MOC.  Each state empowers a board, or group of people, to oversee medical quality and issue licenses to practice medicine.   These boards are demanding proof of competence or MOC.

The state medical boards have come to realize specialty certification is awarded by  national organizations that seems to live in the clouds and often don’t demand real-world skill.  Certification in family medicine, general surgery, ophthalmology, and gynecology are examples of specialties.

The offended doctors object to being forced to learn about MOC subjects like:

  • how to recognize abuse of children and elderly adults
  • teamwork during operating room emergencies (a simulator lab)
  • how to review a chart to identify areas for improvement
  • principles of quality improvement
  • new information about cost effective drugs

Of course, all those topics are a waste of time for busy doctors that stay on the cutting edge of medicine by getting information from drug reps and journal ads.  The high cost of continuing education, $2000 for a refresher course, is ridiculous since that is the usual salary doctor receives for 3 days of work.  Who ever heard of using a simulation laboratory;  it’s not proven.  Practicing on live patients to see what works and what doesn’t  is the way — some live and some die.  Besides, what does a pilot really learn when they crash a simulator rather than a real plane!



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Nursing Quality — paperwork problems

nurseWhen Quasimodo answers your call light instead of the the nurse you know something is wrong.  It probably has to do with all that paperwork — one third of a nurse’s time is spent doing clerical work either on paper or on the computer.

Laura Landro of the Wall Street Journal reported 7/21/14:  “Nurses Shift, Aiming for More Time With Patients”.  Ms. Landro highlights one hospital where nurses are getting more help from LPNs and CNAs so they can spend more time at the bedside.

More low-level helpers — where does that lead?  Probably not to more Florence Nightingales at the bedside but rather fewer RNs who will mainly serve as supervisors.  Nurses are getting expensive so the trend will save money for hospitals.

Nurses are hit from many directions.  Shift-work is hard on family life and the educational requirements have increased.   Highly motivated nurses often escape the shift work by training to become outpatient nurse practitioners — why try to climb the corporate ladder?  Nurses aspire to be more like doctors at a time when doctors as hospitalists become more like nursing supervisors.  And, hospitals don’t see much value to experience —  they fire a 50 year old nurse so they can hire 2 twenty something nurses to save money.

Nursing is not all sweetness and light; there are quality problems:

  • Poor shift to shift communication — who knows what the guy at the end of the hall has?
  • Collection of information that has no value 24 hours later — a huge waste of time.  Unfortunately, the nursing model is focused on filling out forms or online queries.   Always made worse by legal concerns.
  • Training that inhibits drawing a conclusion.  For example,  if a patient is on the floor bleeding from a cut on the head … the conclusion is “deficit of patient comfort”  rather than “scalp laceration and possible brain injury”.  That’s the doctor’s job — too bad the doctor is not always there.





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Asthma Inhaler Costs — ripoff alert

ripoffAsthmatic abuse:  (definition)  The systematic and intentional market manipulation of asthma medication prices resulting in large corporate profits and financial ruin for people with asthma (see also: racketeering, theft, extortion, corruption, complicity and congress).

Price gouging of people with asthma by U.S. pharmaceutical companies is legendary (New York Times).   Now some of those same companies want to move their corporate offices to other countries to avoid U.S. taxes.  RIPOFF is the technical term.

mdisprayAn inhaler is a pressurized gadget to make a mist of a medication so a person can inhale the mist  (see the picture at the right).   It should have never been patented:  it is useful, but it is trivial and certainly not novel.   Now, through patent manipulations and suits there are NO GENERIC INHALERS FOR ASTHMATICS; there are only high priced brand name products — despite the fact this type of sprayer and medication has been available for 40 years.

Albuterol is the most common anti-asthma inhaler.  The drug is easy to manufacture (costs a few cents) and the inhaler is trivial (costs less than a dollar).  The US price listed below is from  Costco (considered the lowest price source in the US).  The Indian price quoted below is from (this is not an endorsement,  just an example).

  • The US price:  PROAIR HFA 90 MCG INHALER (TEV)       $55.46
  • The Indian price:  Ventorlin CFC Free Inhaler / Salbutamol 100mcg  (GSK)    $4.40

These are the same drugs:   US price $55, Indian price $4.   GSK is a reputable UK company that  manufactures albuterol, sells it worldwide, but not in the US.  Without the unreasonable market restrictions and nearly insane FDA rules asthmatics would be able to purchase albuterol for about $4 per inhaler.


Patents should be allowed to exist, but consumer prices  must be limited.  Countries other than the US exercise this control.   Citizens fight price-gouging companies — why not fight price-gouging drug companies?  Medicare insists doctors accept payment at the lowest rate offered, so why should Medicare  fail to insist on the lowest price drug companies offer elsewhere in the world?

The current laws for pharmaceuticals are so complicated it defies understanding.  If you like complexity, like laws and like legal suits then continue the current system.  Instead, consider the following:

What part of this simple rule would be difficult to understand:


That’s the kind of pharmaceutical control the US needs.

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Severe Dementia — guide for the power of attorney

brainSevere dementia comes to an end.  And, as the end approaches the POA (the person designated as the health care “power of attorney”) must face some difficult questions.   Be assured, such questions are not new.  Ethicists and philosophers provide some guidance:

  1. Understand death is near.
  2. Be conservative — try not to interfere with a natural death
  3. Comfort should be the goal.
  4. Avoid tests, treatments or procedures unrelated to comfort.
  5. Approaching death creates emotion.  But, strive for logical decisions.
  6. Discuss the above 5 principles with health care providers and family.
  7. Keep in close contact with family members.

When is dementia severe?  First, it is not something that happens suddenly.  There is a progression from mild, to moderate to severe that develops over months to years.  Finally, the person looses connection to reality and does not remember who they are, where they are or what time it is.   Physically, they they loose coordination, slow down, get weak, don’t talk clearly, frighten easily, anger easily, choke easily, fall easily, and often loose control of bladder and bowels.   Eventually, they need help even with the simple activities of daily living:  like dressing, going to the bathroom, bathing, feeding themselves and even sleeping at the right time.

What naturally happens?  In a modern care setting the most common final events are pneumonia (from poor swallowing), urine infections, strokes,  infected bed sores, blood clots, and falls with head injury or broken bones (like a hip fracture).  Often, a demented patient will have one hospitalization after another.  The person never seems to fully recover.  Any changes in environment, like a new room or new caregivers can drastically worsen the mental situation.  Mental stability is aggravated by restraints or sedatives.  In the end, the person may become unresponsive (a coma) and bodily functions stop.

Who can help the POA?  A severely demented person’s POA will draw lines and make decisions differently.  Hopefully, the POA had a discussion with the patient about end-of-life issues before severe dementia intervened.  Most POAs will still ask themselves if they are doing the right thing.  A discussion of medical facts with the primary care provider helps to put priorities in order.   Social workers can be a world of help.  Clergy often has a big-picture view that is very comforting.  Palliative care programs (if available) can be a relief with a team of doctors, nurses and social workers to give support over long periods of time.  When the patient only has a few weeks to live (according to the attending physician) then a hospice program can help in the final weeks at home or in a nursing home.

Even the best prepared POA runs into difficult questions:

  • At the care center the patient’s hearing aid is lost — should it be replaced?  Answer:  probably not.  It will likely just be lost again.
  • The gastroenterologist office calls to set up a routine colonoscopy, when should it be done?  Answer:  skip the procedure.  It will not make the demented patient live longer and the required sedation may be so disturbing it could cause hospitalization.
  • The patient has no dental pain but the dentist suggests a new crown for a tooth.  When to schedule?  Answer:  no pain, no procedure.  Any procedure can result in hospitalization for minor complications.  If dental pain becomes a problem sometimes a quick dental extraction is the easy answer.
  • The patient becomes unresponsive (in a coma) at the care center.  Should an ambulance be called?  Answer:  probably not.  If a do-not-resuscitate order is in the chart and the patient is in no distress good nursing care is all that is needed.




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What Can You Do For Healthcare?

jfkAsk not what healthcare can do for you .. ask what you can do for healthcare.  The US healthcare system is in trouble — doctors don’t listen to patients and charge too much, there is an increasing shortage of healthcare providers, waiting lists are longer, hospitals often give patients infections rather than prevent them, insurance companies extract high profit and they pay CEOs millions of dollars without much patient benefit.

Yet in this environment patients ask for more engagement with providers (meaning more face time), ask for more informed choices (meaning more education),  ask for lower price  insurance (meaning congressional action), and ask for shorter waiting times (meaning expanding the healthcare workforce).  ASK…ASK…ASK.

There is no question the US system needs change and there is no question people are not getting the attention they need.

So what can people do?  Perhaps you have some answers to the question.  Here are a few suggestions:

  • volunteer to help others figure out medical bills
  • volunteer to help in doctors’ offices pass out educational materials
  • be outspoken if healthcare workers fail to use alcohol gel before visits
  • volunteer to be on quality assurance committees in doctors offices and in hospitals
  • volunteer to do Internet searches to find health information for friends and relatives
  • volunteer to take people who don’t drive to health care appointments
  • don’t go to doctor appointments unprepared — have your records and test results in hand.
  • send messages to your congressmen any time you experience long waiting times, high drug costs, complexity of health insurance, or high prices of medical devices.  If you don’t get results don’t vote for them again.

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Drug Side Effects — placebo and nocebo

goodpillbadpillWhen you question  people given a placebo (containing no medication) 25% will feel better (placebo effect) and 45% will think they have a side-effect (nocebo effect).  The remaining 30% notice nothing.  What a delema for doctors!  Some people feel better without  medication, some feel worse with medication and some don’t think the medication is working either way!

The answer is not to over-think the problem.  Patient’s should become informed about the medications they take — know the top 3 side effects.  And, if something definitely unusual (and bothersome) happens shortly after taking a new medication run down the side-effect list and check with your health care provider.  If a side effect you have is really on the list a response from the health care provider:  “I’ve never seen that” is just not helpful.

Many medications have side effects that people just must live with.  Like strong blood pressure medications that cause a slight dizziness on standing.  Or an anti-allergy medication that causes a dry mouth.  Some people expect to feel better with blood pressure medication — not so — a lower blood pressure is the desired effect, not any “feeling”.

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Hospital as Victim of Pharmaceutical Marketing

gorillaandwomanHospitals suffer (and consumers pay the price)  when drug companies price medications with usage targets and drug baskets.  These techniques are euphemistically called “Guerrilla Marketing” but should be called ILLEGAL  Pharmaceutical companies should be restricted to selling or pricing drugs one drug at a time.

 What’s going on?  The drug companies take advantage of the difficulty hospitals have to convince doctors to stick to a limited group of hospital drugs (a formulary).  When the hospital convinces (by internal marketing) the staff to accept certain drugs it’s hard to reverse course.

  • Usage Targets:  a hospital gets a better price using one company’s drug 90% of the time.   So good in fact, even if a less expensive competitor shows up hospitals don’t change — because the hospital pharmacy does not want to contradict the internal marketing they already did to reach that 90% target.  And, when the usage falls below 90% a huge price increase hits.  If they could totally stop using the drug things would be ok but they can’t.
  • Drug Baskets:  a hospital gets a sweet deal on a blockbuster drug by agreeing to exclusively use a few of that companies low cost drugs.  Later, the drug company raises the wholesale price of the low cost drugs but still gives the hospital the same sweet deal.  It looks like the whole basket of drugs is even a better deal.  But, when the blockbuster drug goes generic it’s hard to figure out what to do.  The basket deal seems good unless the hospital looks for substitutes to the formerly low cost drugs.  Many hospitals stumble on the complexity.  And the staff doctors complain about changes to several drug at once.

When hospitals stumble with these deals who do you think pays the price?  Consumers (that means you).  Guerrilla/Gorilla not much difference.

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