Quality Improvement in Medical Practice - Need for Balance

The quality improvement movement in medicine has been important and fruitful. Nonetheless, many of us have had reservations. The complaints have ranged from the indisputable fact that P4P results reported to our practices are often inaccurate, to concerns that meeting standards and reporting to authorities is often just busy work, to worries that standards often lead to teaching to the test, to the criticism that practices that treat the lower socioeconomic strata (or, practices that treat non-vaccinators) are penalized by the shortcomings of their patient bases. These are all valid. My own concern has been that with a strict emphasis on the measurable, important aspects of quality that are difficult to measure have been neglected. Let me explain.

Two Methods and Two Types of Objectives

There are two methods we can use to effect both clinical and clerical change in our offices. One could be called Systemic Re-engineering (SR); the other would be Professional Enhancement (PE).

SR builds techniques into the office environment with such devices as checklists, explicit protocols, flow sheets, questionnaires, and computerization. SR solutions are “outside the head” and relieve the clinician or staff of the burden of remembering.

PE, on the other hand, happens inside the head, as in, “Remember to….” PE is very familiar to us from our training. We are educated in basic facts, basic procedures, precepts, attitudes, etc.

Just as there are two ways to effect change, there are two types of objectives. Type one is a Quantifiable Objective (QO); the other would be Non-quantifiable Objective (NO).

A QO is generally related to a stereotypical event, such as vaccinating, or diagnosing and treating streptococcal pharyngitis. QO’s are familiar to us as P4P measurements.

An NO may be a non-stereotypical event. Pursuing a difficult diagnosis would be such an event. There is no current way to measure how a clinician pursues signs and symptoms with his or her own acumen, strategic tests, and referrals.

Other NO’s would be based on the human behavior of the clinician. Caring for patients with empathy and compassion would be such a behavior. Another would be attentiveness to a patient’s communication, and patience in eliciting information. A patient satisfaction survey is far too blunt an instrument to capture these qualities accurately, and we have no other applicable means of measurement.

Matching Methods and Objectives

The two methods and the two objectives tend to pair up, SR with QO, and PE with NO. An example of the SR-QO pair would be the stereotypic case of prescribing controllers for asthma and not relying on rescue medications excessively. The PE approach would be to bank on the attentiveness and memory of the clinician when the refill requests come in (“Remember!”). The preferred SR approach might be to institute an office procedure that forbids albuterol refills, and instead compels the staff to schedule a visit when an albuterol refill request is made, and has a flow sheet in the chart that details all prescriptions. The results of this QI effort would be clearly measurable, as we know.

A clerical example of office functioning would be keeping track of vaccine stock. One could admonish clinicians and staff to remember to bill for every vaccine given (PE – remember!), or one could institute a procedure of daily balancing of stock vs. billing sheets (SR). Clearly, for these stereotypical events, SR would be a more reliable and efficient approach resulting in higher quality and less variation.

I have two favorite examples of the PE-NO pair. The first is the issue of pursuing a difficult diagnosis. Perhaps clinical prompts in an EMR would be helpful, but in general it is difficult to think of an SR approach that would arrange a system to help and encourage a clinician to be smart and persistent in pursuing a diagnosis. Yet it is difficult to think of a more important aspect of quality care than this.

A second favorite example is improving the “caring” function. Imagine a possible SR solution: the placing of a sign on the wall reading “We Care!” Clearly, teaching and encouraging how to care for a patient, how to reduce emotional distance is something that still belongs in the realm of PE.

In both of these issues, the PE approach would seem more apt. I can’t think of any fancy and modernistic approaches, but practice conferences with case presentations and feedback (hopefully positive), and in the case of conferences on caring, the presence of professionals from outside the practice with relevant expertise (social work, psychiatry, clergy), could be of great help.

The key is for the practice as a whole to care about these issues, and to make them part of the practice culture. The fact that the effect is not quantifiable should not deter the practice from emphasizing these very important practice characteristics.

Keeping the Balance

As QI has risen in importance in recent years, QO has been emphasized and NO neglected. Perhaps this has occurred because of our scientific prejudice to pay attention only to the measurable and to distrust the impressionistic. Maybe it has happened because of a perceived need to “prove” quality to insurance companies and payers. Both are understandable.

But the imbalance is regrettable. What can be more important than pursuing difficult diagnoses? What can be more important than the caring function? Yet, because they are not easily measurable practices are not paid to excel in these functions. The measurable has pushed out the unmeasurable.

Still, although we are influenced by QI professionals and organizations, and by financial incentives, in the final analysis our practices are ours to shape. If we take steps to improve our practices in these very important but non-quantifiable aspects, we ourselves will feel the richer for it, and it is quite possible our patients will benefit from it. The key is "Not everything that counts can be counted, and not everything that can be counted counts.” (William Bruce Cameron.)

Budd Shenkin

Steve Jobs and My Credit Card Woes

I think it’s time for a few smaller blog posts. I can’t be hamstrung by trying to make every one better than the last. Even at the risk of triviality. But after all, some of my favorite writers – Dave Barry, say – dwell in that region and thrive.

So, I just read Walter Isaacson’s Steve Jobs biography, which is well worth reading, sports fans. Great story and Isaacson is in a class with David McCullough and Michael Lewis and Alan Furst– you can’t go wrong reading what they write. Steve’s wife, Laurene Powell, said he’s a great man, but great men are not great at everything. So personal relations and being nice to others weren’t his strengths.

But he was frank. There were a lot of gadgets, devices, architecture, a lot of things that he pronounced as shit. The whole music industry didn’t get it as their business went kerplunk. It took Itunes to get it right and save them, and it was an outside agency that did it, not they themselves. Sony had everything together to do an Ipod and they didn’t do it – why? Because they were divided into divisions and the divisions didn’t and couldn’t work together. So an outsider, Jobs, did it.

BTW, this invention is an example of the incorrectness of the description of innovation as “find a need and fill it.” Instead, he visited Toshiba, I think it was, and they said, we invented this 1.8 inch hard drive and we can’t figure out what to do with it. Jobs thought, I can do something with this, and brought together technology, his love of music, and his identification with the general consumer to think, Ipod. The technology advanced and he found the use for it. This is generally what happens – like the telephone, recording devices, the computer itself.

Anyway, let me be inspired by Jobs’ ready indictment of the ignorance of others. About three years ago I made a mid-year’s resolution. I was leaving my credit card behind at too many restaurants, and in my car I was pulling out of my lane without looking too often (all the time, actually). So my resolution was to stop forgetting my credit card, and to look before I pulled out.

Perspective: whenever there is improvement to be made, there are two ways to do it, personal improvement or systematic re-engineering. When I want to make an improvement at Bayside, that’s the choice I have – ask people to try to remember, or build it into the system. Sometimes one strategy is appropriate, sometimes the other. In the case of my credit care forgetfulness woes and my driving woes, since I’m just an individual, only the individual strategy is open to me – be aware, remind myself at the table and at the wheel, take the card and look first.

Jobs was in the position that he could look at a device, how much a customer needed to remember to use it, and say, This is ridiculous, and make a better, more intuitive device. In the Apple stores he realized how inefficient it was for a customer (the customer’s view!) to have to line up to pay for a purchase. Reminds me of the old Soviet stores where you lined up to look at something, lined up again to get the item, and lined up again to pay for it. So Jobs had the employees have those little devices that paid for the item right on the floor – just as in Europe as they do in restaurants.

But what do they do in restaurants here at home? Here, they take your card away, bring it back, and then they HIDE THE CARD INSIDE THE CUSTOMER’S RECEIPT! How many of us want that receipt, for God’s sake? The way they do it now, I have to prompt myself to take the hidden card out and put it in my wallet. It’s just not going to work all the time, but this is the way they keep doing it. Ridiculous. Where is Steve Jobs when I need him?

So, I’m here in Hawaii and the other night I left my card behind again – got it later, but what a pain. This is a stupid system and they’re all doing the same damn thing, hiding the card! At least I can rant and recognize that this is what Jobs was a specialist at, ranting about the idiocy of others. I’m in good company.

Oh, and one more thing – in my new car, an Infinity, there is a little light by the door that lights up when there is a car in my blind spot. All I have to do is remember to look at it. What they need is a bell that goes off when my wheels start to turn and the light is lit.

I read the Steve Jobs book, I understand the power of being right – No More Mr. Nice Guy!

Budd Shenkin

The Desert of Quality of Care in Diagnosis

The reader will remember the stirring account of my recent neurosurgical adventure. The initial part of the adventure was essentially a misdiagnosis by my ophthalmologist. Despite the facts that, one, my eyesight was clearly deteriorating, and two, the very small cataracts in each eye were unchanged -- nonetheless, my ophthalmologist sent me home with literature on cataract removal, and instructions to tell him when I was ready to have them removed. I struggled with my feeling on the one hand that something was more profoundly wrong than that, versus my respect for a doctor’s opinion on the other. Silly me. Eventually, as I exerted pressure for a better diagnosis, my pituitary macroadenoma impinging on my optic chiasm was revealed as the cause of my progressive blindness.

What I didn’t anticipate was the response of fellow physicians to this misdiagnosis. One friend, plastic surgeon Steve Daane, was outraged: “You were misdiagnosed!” My pediatrician friend Arnie Blustein noted that this is a classic case of the kind of mistake in doctor thinking described in Jerry Groopman‘s book, How Doctors Think. As Arnie said, once they get an idea what the diagnosis is, they twist logic to come to that conclusion and just hang on. In my case, the cataracts had nothing to do with my decrease in vision, and if the ophthalmologist had used his head and gotten a simple visual fields test, he would have discovered my pituitary tumor impinging on the optic nerves. But he didn’t. Funny, I had read the book but it took Arnie’s observation for me to connect my plight to Groopman’s, as recounted in the book. I guess I’m not so smart as I sometimes think I am; I’ll have to reread it.

But what’s even more interesting is the number of doctors who recounted similar incidents in their own medical care! Here is the list:

• One pediatric colleague had had GI symptoms for some months, and his doctor said, you’re just constipated. My colleague didn’t think so, but went along with the suggested remedies. He subsequently arrived in the ER with fecal obstruction. The diagnosis in the ER was constipation. My colleague objected, insisted on and pulled strings to get an MRI, and an obstructing colon cancer was found. (He is now fine, having finally gone to UCSF for treatment.)

• Another pediatric colleague, a runner, was recovering from back surgery when he took a turn for the worse. The diagnosis was that he hadn’t rested enough and was “pushing it.” He objected to the diagnosis, insisted on blood tests, and he was ultimately diagnosed with osteomyelitis at the surgical site.

• Another colleague had had nagging pain in the right buttock and leg. He was advised to get physiotherapy. He insisted on an MRI, got his internist to sign off on it, and a five pound tumor was found in his buttock.

• Just yesterday, a neonatologist colleague told me about his searing right upper quadrant abdominal pain, diagnosed by a GI specialist as a clear case of a spastic gall bladder, which should be removed at once. My colleague suggested an MRI or CT scan, which the specialist refused to order because the case was so clear-cut. My friend went back to his internist to get his wish for a study fulfilled, and the culprit turned out to be a ureteral stone just above the bladder, not a gall bladder case at all.

What to make of these cases? An anecdote is just that, an anecdote, and even multiple anecdotes do not rise to the status of data. But while they don't prove anything, I think these anecdotes really do illuminate a probable truth. I think it i probably true that diagnostic medicine as commonly practiced has a very high rate of errors. This is a sobering thought, but probably true. It’s what my father told me long ago; as a community based neurosurgeon he saw a lot of how medicine is practiced, and it didn’t inspire confidence. His counsel to me was to be very careful whom I chose to be my doctor.

All these anecdotes concern doctors as patients. It’s possible that doctors get worse care than do ordinary patients. Treating physicians might be more nervous with a doctor as a patient, and they might not treat their doctor-patients as they do other patients and leave things out, try extra hard to appear confident, etc. But I think it is more probable that doctors are more alert to physician mistakes than are lay people. We just know more about what goes on, just as a general can tell a bad battle plan and bad commander reactions to enemy actions better than an architect can. I think that there is a lot of this bad diagnostic medicine practiced all the time and everywhere, but doctors get away with it.


From another point of view, it's amazing that such a poor diagnostic landscape exists. After all, there is a very active movement in medical care to measure quality of care. I won’t recount the history here, because it is long and complex. But the amazing thing is this – none of these adventures in misdiagnosis would be caught and cited by any current effort to measure quality of care!!! (That’s right, three exclamation points. After all, what could be more important than these misdiagnoses, and yet they are off the radar screen, by design! OK, now I’m down to one exclamation point.)

In outpatient medicine, it is very hard to measure quality of care, or even to define it. The most recent quality movement has been P4P, or Pay For Performance. P4P uses data from billings – the ease of data acquisition in P4P is its biggest selling point – and assesses to what extent regular, stereotypical procedures have been carried out. For instance – immunizations. There is a regular schedule for giving immunizations to children, and each shot should be billed for. Thus, a quality indicator for a practice is, what percentage of patients in a practice have gotten all the required shots by age 2? Or, another example, in a patient hospitalized for a heart attack, what percentage of patients had a beta-blocker prescribed by the time of discharge? Again, the ideal percentage would be 100%, so the rating is unambiguous. These are stereotypic procedures that should be done for every patient of that age or with that diagnosis, every time.

In the case of my ophthalmologist, a regular, stereotypic procedure would be, does the practice measure intraocular pressure every year, to detect glaucoma? I assure you, in this practice, they measure 100% on this; I have never been there without my intraocular pressure being measured.

But how could there be a method for detecting the timely (let alone early) diagnosis of my problem? How could the diagnostic acumen of the doctors in thes other cases of misdiagnosis recounted above, be assessed? Actually, I can think of several ways, but each would be difficult, expensive, and not possible in the typical small office. Quality assessment is really hard to do.

But, I do have a proposal. It goes against the grain of current quality assurance or quality improvement programs, because it is not quantitative – quantitation has infected medicine worse than MRSA has. You just can’t mention anything in quality assessment until somebody’s left brain kicks in, and someone pipes up as though they had a personal connection to the scientific Taliban, “How can you measure that exactly?” As though they were the smartest ones in the room. Drives me nuts.

Anyway, right now practices get paid extra (actually, their withhold of payment is restored, but that’s not the way the insurer’s portray it) if they meet the quantitative measure of keeping enough patients fully immunized. My proposal is this: the practices should be paid if they can show that they regularly review diagnostic problems within their practices and discuss them with each other.

The scientific measurement Taliban will reject this as “inexact,” but still, what gets talked about and what gets paid gets the attention, and the more we ignore diagnostic prowess the worse it will get. So I say, tell the practices they should have these procedures of diagnostic review, set some criteria for them and pay the practices that set such a review up.

There is a legal problem that would have to be solved for this proposal to work. In the hospital a quality committee’s deliberations are legally non-discoverable. This confidentiality allows true quality work to proceed, for obvious reasons. Without that protection, the quality committee’s work would be adversarial from the start and no one would agree to staff it. The diagnostic quality review committee in outpatient care would need similar legal protection.

So, in summary, I think diagnostic accuracy in community medical care probably is sorely deficient. If my colleagues and I can’t get it, you probably can’t get it, either. Caveat emptor – get that second and third opinion whenever you feel uneasy. And second, I propose that the quality movement change its focus from being exclusively on the repetitive, stereotypic, quantifiable procedures, and start to focus more on the harder to measure but ultimately at least as important area of accuracy of diagnosis.

Note to insurance company – I am available as a consultant, as I am not currently otherwise occupied occupying Oakland.

Budd Shenkin

Bookstores, The Kindle, and a Solution to a Moral Hazard

My wife is a bookstore junky. We’ll be walking along, or even driving along, and she will spot a bookstore and head for it. Even in the shoppers’ paradise of the Dubai Mall, the main attraction was a great bookstore. She even has destination bookstores at various locations – it used to be the Thunderbird in Carmel, that bookstore near the Metropolitan Museum on Madison in NYC we were in earlier this week, and is it Smith’s in London? And I have to admit, I’m right there with her – she’ll be on her feet more, but I’ll settle into a chair and read a likely candidate for purchase.

There is really nothing like a bookstore. The best stores display books they recommend that you might otherwise not notice, each has its own personality, and you can look the book through in your own way to see if it’s for you. Plus there is the group experience as other book lovers mill about.

So, you want to support bookstores and buy the books you find there, and not run home and order the book you found from Amazon at a cheaper price, often substantially cheaper. You want to discipline yourself to buy the book there where you find it, and keep those stores in existence. Which we do.

But now the Kindle has made it harder. Not only is the book substantially less expensive on the Kindle, sometimes you don’t want the physical book, you want it on the Kindle. I love reading on the Kindle, even though I enjoy the look and feel of real books, the memory of book covers, and the ability to scan back in a way that is better than on the Kindle. But for me somehow I read the Kindle faster and easier, and it travels very, very well. So, there you are in the store, you have found a book you want, but you want it on the Kindle. It’s a harder choice than it has ever been.

Plus, there are probably people less scrupulous than we are, who make it a regular practice to shop actual and buy virtual. They can rationalize that they are pressed for cash, they can make other rationalizations, but the moral hazard still exists.

I don’t know how widespread this problem is, or if anyone knows how widespread it is, but if it is widespread, I have a solution. Here it is:

HAVE AN AMAZON CONNECTED COMPUTER IN EACH BOOKSTORE. IF A CUSTOMER CHOOSES TO ORDER THE BOOK ON THAT COMPUTER RATHER THAN BUY IT DIRECTLY FROM THE BOOKSTORE, THEN SPLIT THE PROFIT BETWEEN AMAZON AND THE BOOKSTORE.

I don’t know how the numbers would work. Would people do it? Would they order right there in the bookstore? Would too many people be tempted to buy it on Amazon, when without this connection in the store they would just have pIcked it up at the store and the store would have enjoyed the whole profit themselves? Would this be an attractive proposition for Amazon?

I don’t know the answers. But I do think it would help me out of my moral dilemma. I see the book, I want it on my Kindle, and what am I going to do? I sure would like to give each of them some profit, and have that book the way I want it.

Budd Shenkin

Welcome to Neurosurgeryland

WELCOME TO NEUROSURGERYLAND

I thought our big adventure this year would be our trip to East Africa. Well, that trip was terrific, for sure. But our biggest adventure turned out to be our trip to Neurosurgeryland. Be warned: this is a long post, 6,000 words probably. But I’ll do my best to keep it moving along.

My Life as a Neurosurgical Son

I was the eldest child in a neurosurgical family. I say “neurosurgical family” because when your father is a neurosurgeon, that’s the whole deal right there. Neurosurgeons tend to be Ayn Rand hero-types. That’s what my Dad was.

He got to be a neurosurgeon because of his father, who was a general practitioner (and also billiards champion) of Philadelphia. The story goes that one day in 1932 he blew his nose too hard and the infected phlegm went backwards through his ear, causing a cerebral abscess. With no antibiotics and only rudimentary brain surgery, he soon died. My father was 17. The attending neurologist put my Dad to work as a neuropathology technician, and soon doctors were calling him directly for his reading of the slides.

As my Dad was at the end of medical school the first neurosurgeon in Philadelphia, Francis Grant, came to him and asked him what he was going to be. “A neurologist, I guess,” said my Dad.

“Well, you know,” said Dr. Grant, “if you are a neurologist you will have to do psychiatry, too, to make a living. Why don’t you think about being a neurosurgeon?”

Much to the advantage not only of my father but a myriad of patients who would be seeking psychiatric advice, my father became the third neurosurgeon in Philadelphia.

The next part of the family story is that my father could not stay at Penn although he wanted to. He was Jewish. Dr. Grant said to my Dad, “We did it for Rav (Isidor Ravdin, internist), but we can’t do it for you, Henry.” My Dad stuck to that story, but one time years later he said that it might have been his personality, too.

My Dad wound up as Chief of Neurosurgery at Episcopal Hospital in North Philadelphia and perennial President of the Medical Staff. He has a list of “firsts” he accomplished as a nationally and even internationally known neurosurgeon, but his favorite had to be owning the first CAT scanner in Philadelphia. It operated 24 hours a day, and when they called for an appointment from Penn, my mother would be happy to give them the open 2 AM slot.

I idolized my father, but when I was in medical school he put no pressure on me to become a neurosurgeon, and in fact urged me more toward administrative or academic medicine. He rightly saw that if I chose the neurosurgical path, it would have to come from me. But I chose pediatrics. When my father announced this choice to his hospital lunch table colleagues, there was a silence. Someone spoke up, “But, Henry, those guys work so hard and they hardly make any money at all!” Silence. Then, “Can you talk to him?”

Even though I seem to have a “surgical personality,” pediatrics and administration has been great for me, a real mitzvah. But I remained a neurosurgical son, at home in Neurosurgeryland. When my Dad had a reunion of his residents at a Harvey Cushing Society meeting in San Francisco, I was asked to speak. I told the residents that we were all his sons. They loved him.

My Dad died at age 92 in 2007, his last accomplishment having lived to the age of 92. He was a man of objectives. He told me in his 80’s that he figured that the goal now was to live long, so he reduced his diet and made it to 92. “Made it to 92,” was one of his final statements. He observed many times – many, many times, since he was not one to deny himself the pleasure of reiteration -- that he was born when horses were the general mode of transportation in Philadelphia for God’s sake, and that his generation had seen the most amazing transformation in technology not only that the world had ever seen, but much more than anyone could ever have imagined. Just in his own field, my Dad had gone from relative helplessness with his own father’s illness, through the techniques that my Dad and his generation created, and then beyond. (My own view is that advances in medicine and in space and physics exploration are the quintessential advances of our age, even more important than the securitization of mortgages.)

As if to prove the point, just seven months after Dad died, I got my hip resurfaced (slightly more advanced than the traditional hip replacement.) I had told him I was having some trouble with it, and the kindly (he was kindly with me) neurosurgeon said, “Get it fixed.” Spare parts replacement surgery. If you think about it, wow. Star Trek.

Ophthalmology

So that was fine, but then last year I started having some trouble seeing. I had always taken pride in my eyes; even here in my late sixties, in strong light I have been able to read the New York Times without glasses. But I thought Father Time was catching up with me. My prescription hadn’t changed and I got checked up each year, but I was having real trouble seeing. I went to the ophthalmologist in December 2010 with pretty severe complaints. I couldn’t see anything on the eye chart with my left eye, and my right one wasn’t so great, either. My ophthalmologist said that my vision hadn’t changed a lot (that was hard to understand), and the small cataracts I had shouldn’t really affect my vision that much. But nonetheless, he didn’t delve further and gave me a packet of information on cataract surgery.

It didn’t make sense to me, but I thought maybe he just wasn’t paying enough attention to helping my vision. I thought I’d try to do that, so I went to the optometrists at UC Berkeley, who used terrific new technology to map my whole eye on each side – fantastic, granular pictures of just every part of my eyes. Star Trek. I wondered with the optometrist, since the cataracts don’t explain the vision loss, if there was something neurological going on, since the exam of all aspects of the eyes was so normal. But it was left at that, a wondering. He asked me to come back to try one or two things more, but I let it go. I got new glasses for reading and that helped some.

My eyes got worse. I had trouble making out a wall menu when the lettering on the wood was in yellow. I thought the type on some of my books was faint. I felt often the way you do when you have looked at brightness and your eyes have yet to accommodate, but they never would accommodate, and I was just left with the glare. Ann and I took a wonderful trip to Africa, and she could see game that I had to look twice or three times to see. We came home and were about to go on a long-planned trip to Hawaii with my brother and sister-in-law, and I said, “I have to go back to the ophthalmologist. My eyes suck.” Maybe it was just age, but I had try again, even if he might just say, get the cataract surgery.

So I did. The house optometrist asked me why my vision was poor (I said, you’re the doctor! To which he took offense), and then why I hadn’t had my cataract operation. They had only done a partial transition from paper to electronic medical records, but he eventually was using both to trace my history. He refracted me (not sure why). Then he looked at my left eye’s progress over the last few years – 20/40 to 20/60 to 20/80 to 20/100. But the size of the cataract hadn’t changed. My ophthalmologist came in and seemed puzzled. I asked him about neurological disease – I’m too old for multiple sclerosis, but something was happening. I told him many of my symptoms. I was emphatic – when I read I can’t use my left eye at all, and I’m scanning with my right eye. Finally, he said he would do further testing. He looked at me as though I had pushed him enough. I could only make out one of the numbers on the Ishihara color discrimination test – but that’s OK, he said, you’re dilated. He asked if his office could set up an appointment with a retina specialist. He asked me to make an appointment to come back for a visual field test.

I went out front and the staff made the retina appointment with the wrong group until I corrected them. I insisted on giving my cell phone number to the front desk person who didn’t seem to know what to do with it on the electronic medical record. I was about to leave when someone came around the corner and said they could do the visual field testing now after all, if I could wait. Of course I could. The tech came and got me for the tests, chin up and one eye looking straight ahead, thumb clicking on device every time I saw a flash of light in various quadrants. The tech excused himself during each test because it was so boring for him to sit there and watch. I left and ate an early Japanese dinner with my step-daughter Sara, a UCSF pediatrician, and 1 1/2 year old Lola. I told Sara I thought I could have a brain tumor of some sort. Then I went home.

The ophthalmologist had left a message on our home answering machine – call him, he didn’t have my cell number, so he is calling here at home. I called and he said, you have both eyes involved, the upper outer fields in both eyes are cut. So there is something going on at the optic chiasm, where the optic nerves cross, right in the middle of the head above the pituitary gland.

“So I need an MRI,” I said.

“Right,” he answered.

“So I’m not going to Hawaii tomorrow morning, “ I said.

“Right,” he answered.

I called my wife who was already there in Hawaii. I explained what was happening. She said, “I think I’m going to cry.”

I said, “I think it’s going to be OK.” The most common thing for it to be would be a pituitary adenoma, which is operable and non-malignant. I was counting on that. I told her not to take the red eye home, let’s see what happens tomorrow.

She called Sara, who called me and said she wanted to come with me to the MRI. I could handle it alone, but I was grateful and I accepted. My father said that every family should have at least one doctor in each generation.


The MRI

It was Thursday now. The ophthalmologist’s office called at 9 AM. They said they had me scheduled for the MRI on Friday at 7:30 AM. I said, “No.”

She said, “What?”

I said, “I’m getting my MRI today. Who did you call?”

She said, “I called all around.”

I said, “Did you tell them it was for Dr. Budd Shenkin?”

She said, “No, I asked them when they had an opening.”

I said, “Did you call Stuart London’s office?”

She said, “No. I should have thought of that.”

We rang off. At 9:20 she called me back and said, “Dr. London has you scheduled for 12 noon today.” I thanked her. He had bumped somebody less acute, who wasn’t going blind.

I had to get my blood tests to him by noon so I could be injected with contrast. The local blood draw station for Labcorp got stat lab results by the end of the day. I went to my old home hospital, Summit, and they got the super stat labs to Dr. London in an hour.

I went home and did some scanning and shredding – I’m making my home office as paperless as possible, Ann’s too – and Sara and I went down to get the MRI. They did my test while she got a sandwich at Ptomain Heaven, all that is available at 34th and Telegraph in Oakland. When my test was over, Sara and I were escorted back where Stu could review the MRI with us.

Stu looked at me with compassion and professionalism and took us to the computer and said, “You have a macroadenoma of the pituitary. It’s 4 cm by 3.2 cm by 2.8 cm. It has extended first down into the sphenoid sinus and then up to squash the pituitary against the side of the sella turcica (the seat of the pituitary, which has a floor and pillars on each side, so it’s like a throne), and it is putting pressure on your optic nerves. What are your symptoms?”

I told him. Then I asked the obvious question, to which I really knew the answer, but I wanted to reassure both of them, in a way. “Is it operable?”

“Oh, yes, it certainly is,” said Stu.

Ok, then. “Where should be go, Stu?” I asked.

He shrugged, “UCSF. You don’t want to go local with something like this. No disrespect to the local guys.”

Of course. That was my view as well. I knew Charlie Wilson had pioneered the nasal approach to the pituitary years ago right here at UCSF, which was my home institution, and for years I had insisted on PPO insurance so that if something like this happened, I could go there. Charlie Wilson was always my explanation when I signed up for PPO. Not that I planned on it. (See http://www.newyorker.com/archive/1999/08/02/1999_08_02_057_TNY_LIBRY_000018760, for the New Yorker's essay on Charlie Wilson.)

After thanking Stu, Sara and I left with the disk of the MRI and she grabbed my arm above the elbow, in support. I didn’t feel any angst at all. I knew this was doable.

We walked to the car and called Ann on the Bluetooth speaker phone, and told her. She said, “You two aren’t sugar coating it, are you?”

Sara and I looked at each other to make sure. Then we both said, “No, we’re not. It’s really going to be OK.”


Starting with Neurosurgery

I called the ophthalmologist and told him the result. He said that all my vision would return. From his lips to God’s ears, and the ears of his malpractice carrier. I told him that my goal now was to find the best surgeon and be operated on by the middle of the next week. He advised going to UCSF, saying he had had a couple of patients there. I asked him to try to get me an appointment asap, and tell them I’m on the clinical faculty there, etc. But move on it. He agreed.

We checked other sources. Sara pulled up the bio on Sandeep Kunwar, the chief neurosurgeon at the Pituitary Center at UCSF. It said he had the largest series of pituitary adenomas in the country. Another colleague of Sara’s, a neurosurgeon in Sacramento, called her to say there was no reason not to go to Dr. Kunwar. I called other sources, who eventually confirmed the choice. I hoped he was not on vacation.

He wasn’t. I scanned and shredded some more, ate dinner at Asmara, my favorite Ethiopian restaurant, and called my brother to tell him the change in plans. He would have to figure out whether to go to Maui on his own with Susan, or change plans. I talked to Ann a few times. She would head home the next day. I felt fine, although I still couldn’t see very well.

On Friday morning I got a call from Dr. Kunwar’s office, asking if could I come to his office in Fremont at 12 noon. apologizing for the short notice. I said I thought I could make time in my schedule to be there. I scanned and shredded, did email, and left to be on time. I was taken back to the exam room at 12:20 and they apologized for keeping me waiting. Dr. Kunwar arrived and apologized for keeping me waiting.

Dr. Kunwar introduced himself as Sandeep Kunwar, informally, just the way Mike Ries had introduced himself when I had started seeing him for my hip. While being friendly and informal and very warm, he was brisk and practical, with no time for traditional formalities like listening to my heart or even examining me. He had the MRI and didn’t need anything else. He asked me about my UCSF and UCB connections – he graduated at UCB, and had done all his medical work at UCSF. I asked him if he trained under Charlie Wilson. He said yes, he trained with him, and then took over his practice. “Great,” I said. We are part of the same club.

He told me he would go over things I no doubt knew, and I said, right, treat me like a patient. We nodded understandingly at each other. As he started I interrupted briefly. I said, “I have to tell you, I come from a neurosurgical family, so coming here I actually feel right at home.” He was interested. I told him about my Dad, whom he hadn’t heard of. I said, “I remember coming down in the morning and my Dad wasn’t drinking coffee because he had a brain tumor that morning, and he didn’t want his hands to shake. So here we are.” He shook his head in understanding, right. I had been more worried with my hip than here with my brain. (As Woody Allen said, “Not my brain! That’s my second-favorite organ!”)

He then gave me his personalized rap. The facts of the case were straightforward. He said I had probably had this tumor for eight or ten years. Below 45 years of age they usually produce a hormone, over 45 years they are non-productive. Sometimes they are prolactinomas, but not usually. It had expanded down into the sphenoidal sinuses without noticeable symptoms. It had also flattened out the pituitary and doubtless wiped out several of my hormones. He said the first one to go is Human Growth Hormone, but in adults patients don’t notice anything. (I wanted to say I had noticed a loss of power from the right side of the plate, but restrained myself.) Then thyroid goes, then testosterone, and then cortisol. The thyroid and testosterone are easily replaced by a pill and a gel, but the cortisol is harder.

He asked about my symptoms. I told him I had been on supplementary thyroid because my internist had taken a test just on the basis of ageing and found a little deficiency. My libido had been down for some time, which I found to be a relief. He asked me about general vigor. I’m in very good shape, so I turned my palms out and straightened my arms to say, “Look at me. I’m 69.” He said, “But you could be even better!” Some slow wound healing maybe, but I didn’t mention that. Dry skin. Still, basically unnoticeable except for the vision. He said that once squeezed, the pituitary doesn’t recover significantly but we could replace everything, it looked like.

After the tumor had squeezed the gland and grown downward and obliterated the sphenoidal sinus, it started to go up, meeting the optic chiasm. That’s what had brought me to this exam room.

These tumors can be either spongy or more rigid, in a spectrum from about 20% (spongy) to 80% (rigid). They come either like hard-boiled eggs that can be easily peeled out from the shell, or more like cauliflowers that are harder to resect. Problems with resecting come if they have wormed their way into something that it’s hard to get them away from. The cavernous sinuses would be number one. A nerve can also be a problem. But even in these cases we get most of them. They are slow growing, so if there happens to be some left behind we just follow it with serial MRI’s and then if it gets bigger, we cut it with a gamma knife, just tightly-focused radiation.

The approach used be under the lip with Charlie Wilson, and is now through the nose. You break through the sphenoidal sinus, which we won’t have to do here because the tumor has already destroyed it. Then you follow it in, debulk it from the inside, then go carefully with each surface of it and pick it out. Then put some fat he would get from my abdomen into the sella, which the tumor had enlarged, like the foam we use to take up the extra space in packages. He told me he had done over 2,000 of these operations now, and the risks are down to under 1%. That’s a good number. He said I would regain the vision I had lost in the last 3-6 months, but that the endocrine function lost would not likely return, but could be replaced.

He said he operated at both Washington Hospital and UCSF. He went into private practice and operates in Fremont because he has a technology and he wants to do more with it, go different places in the body, and you can do more off-campus. It’s funny, he said, you would think you could innovate more on-campus. But in fact UCSF is great for the science, but off-campus is best for technology. I could choose where I wanted to be operated on, it didn’t matter to him, each has its own strengths and weaknesses. I didn’t ask more about that, I just wanted the earliest date available. That date turned out to be Wednesday, August 3 in Fremont. It would be less than one week from ophthalmology appointment to operation, which was my goal, so long as I got the best neurosurgeon, which it seemed like I did. As I left the front desk to get my blood tests, he left the opposite way, waved and said, “See you Wednesday.” I responded, “Be there or be square.” We smiled at each other.

I got my blood tests, collected my paper work and drove home. It was set. I had my man and I had my op date. I was very comfortable to be back in Neurosurgeryland.

The Operation

I picked up Ann at the airport that night to the relief of both of us and filled her in. Over the weekend I worked out, did some work (scanned and shredded), notified near and dear, decided with this risk level that son Allie didn’t have to come from his home in Panama to stand by, decided to let leadership at Bayside know the prospect but to wait until post-op to let everyone else there know – why worry them? - took grand-daughter Lola to the merry-go-round and the little farm in Tilden Park on Sunday, got the pre-ops on Monday, did more work on Tuesday, scrubbed hard in showers Tuesday night and Wednesday morning and slept in freshly washed sheets and pajamas to minimize infection risk, loaded up my pill boxes for two weeks, got packed up with slippers and pajamas by Ann, and we drove down together on Wednesday morning, all ready.

The anesthesiologist came and we talked. He was a Stanford guy, which was reassuring. I remembered Reagan’s aplomb as he was wheeled into surgery after the assassination attempt, “ Any of you guys Democrats?” So I confessed we were Cal people. He recalled gifts of cases of wine he had received from former patients. Stanford guys…. He shot me some Versed. I said, “I like Versed.” He said, “Who doesn’t?” That’s the last thing I remember before waking up in the recovery room – no ICU, even – and Peter and Ann thought I looked ten years older. I got morphine and was fine.

First thing I did when I woke up was look around and check my vision on signs. My left eye was working fine, already. My right was better, too. It had already worked.

At nine PM Dr. Kanwar came by. I asked him what else he had done during the day. He said, two other cases, a spine and something else, the clinic, and then a gamma knife conference. He’s 44 years old and full of energy – the perfect age, and the perfect intensity. He told me my tumor had come out completely – it was hard-boiled egg, not cauliflower. My tumor was the size of a small tomato, almost as big as they get, and very rigid, almost like cartilage, maybe 90% on the spectrum. It had probably been there for 8-10 years. He said that since it was so fibrous, there were only a handful of surgeons in the country who could have handled it – he wasn’t bragging, he’s not a braggart, it was just fact. Good choice of surgeon. Wow. And here I was just conversing with him after his being in the middle of the brain just a few hours ago. As Ann said, it was scary that he was in the middle of my brain, both literally and figuratively. Ann’s a funny person.

I told him, “I don’t know how much you make, but whatever it is, you deserve a lot more.”

Recovery

The first night was morphine, the second night was hydrocodone, then it was home on Friday. Ann sat with me and 27 year old son Pete did, too. Ann ministered to me as she knows how to do – second major surgery in three years. Over and out, hopefully. She told me not to be abstemious with the hydrocodone, which I tend to be, to keep ahead of the pain.

I told Pete, “I feel fine!”

Pete laughed and said, “Dad, of course you do, you’re on hydrocodone!”

Pete urged me to name the tumor. Didn’t want to do it then. Subsequently settled on “The Tomato.”

The ophthalmologist’s office called to find out what happened, so I called back and told them. We let Bayside know I was fine and they could let out the word. We let near and dear know.

It’s good for a doctor to experience the other side of health care. It makes us better doctors. I noticed the hospital. The room was good size and private; the TV was flat screen with a pretty good cable range of shows, including Giants games. The nursing was attentive, each nurse with his or her own personality. Kim fought playfully with me about how we were going to keep me un-constipated while taking pain meds. Roy said his charge nurse wouldn’t let him leave Mylanta by the bedside because it was a drug, and he hoped I would understand because he didn’t want to get written up. I had my blood drawn at 4:30 AM each day. The default channel on the TV was constantly rotating nursing conferences about their quality efforts, very earnest. The charts on the walls as I took my walks were about steps toward quality. That’s good. Think of how hard it is nationally to get hospitals to take action for quality – very difficult. Large groups of people like American hospitals are, by definition, average. Yet national imperatives have filtered down to hospitals well, and progress is evident to a patient like me.

The night before discharge Sandeep’s PA Joe repeated the rules of recovery again: Two weeks of no work, no lifting, lots of reading, some walking, and no blowing the nose. Then two weeks of limited work. Then done. Expect sinus headaches for a couple of weeks. Use Ocean Spray. Things in my head were rearranged and we needed some time for it all to sclerose in and become settled.


At Home

When I got home Ann brought me meals in bed. I followed her advice on meds and rest. I appreciated her ministrations and other secondary gains. I had thought about cautioning others that I didn’t want a fuss made. Then I thought, what’s wrong with a little fuss? Forget the Mr. Cool. Emails, flowers, cards, books. Food. On Saturday Stu Lovett came by with blueberry pie, and we visited. He said he saw my car out front so he figured I was OK. Ione with a stew. Marjorie and Michael with a great salmon dish. And as with the hip, a sandwich from Andronico’s tasted like no other sandwich ever tasted – last time tuna, this time ham and cheese. Cards from people and group cards from some Bayside offices. I choose to believe that these are real expressions of person to person concern and affection. I’ll take it.

I followed Bobby and Susan’s Maui adventure each day, they came back for two days here, used some Giants tickets and loved the stadium, visited for an hour in the sun with old and very dear friend Bob, and as Hemingway would have said, it was good.

I started feeling better, but then Peter sat me down and lectured me: “Dad! You’re not following the orders! You have to take it easy! I saw you picking Lola up!” He was impassioned, frightened for me, and he was right. I thanked him and pledged to be a better patient. I appreciated his concern and his love

And then there is my vision. I kept checking it out. Would it get better still? I walked around the block with Sara and Lola and I thought everything looked more colorful, and the air was clearer. There was no glare. I can see my cards in Freecell more clearly; I can read the numbers on the squares clearly in the New York Times crossword – still can’t do the puzzle all that well, but at least it’s not because of my eyes. I can read real books. I decreased the font size on my Kindle so I can read it faster. What a gift!

I saw my friend Joel the urologist, and we talked again about our OB friend Hank, who died in May of malignant melanoma. He had told Joel that he felt like he was in a speeding car and couldn’t get out. What an image; I understood it. I wish Hank could have gotten out, but even if he couldn’t, I was thankful that I could. Joel said, retire, man! He recounted those who worked too long. But we love our work. The trick is to keep it in its place, I said. Yes, he said, keep it in its place.

After a week I drove into the Oakland office so they could see for themselves. I was home free.

Endocrine Follow Up

The following week Ann and I drove to UCSF to see my endocrinologist, Lewis Blevins. He told me I looked so young, and we would wait six weeks and take hormone levels and see what needed to be replaced. He said that he has been at three different institutions with different neurosurgeons, and Sandeep is the best. He used to say to patients that post op, 1/3 will have worse endocrine function, 1/3 the same, and 1/3 better. With Sandeep he says 5% will have worse, 10% the same, and 85% better. Neurosurgeons are not fungible.

He said that he didn’t see why neurosurgeons don’t refer all pituitary tumors to UCSF. There aren’t enough of either pituitary tumors or neurosurgeons to make a financial difference. Maybe it’s the neurosurgical personality, the ego. I agreed with him. There are two current theories for organizing health care. One is vertical integration, or integrated networks, like Kaiser. The other, as suggested by the book “Redefining Health Care” by Porter and Teisberg, is centers of excellence, where a primary care doctor or a patient him or herself, could choose among competing centers for quality, cost, and accessibility, for each individual affliction. I’m in the centers of excellence camp. Made sense for my hip, made sense for my pituitary. I found the centers where problems from other docs were referred to for repair, and I just went there straight away. Makes sense to me. Surgeons and centers of excellence are not fungible.

What I Make of All This

So what do I make of all this?

First of all, I’m on Medicare and a Medicare supplement – so notice, not once have I said anything about a network, calls to insurance companies, or cost. I paid only $50 for the refraction done at the ophthalmologists. Medicare has great problems, but they sure aren’t on the patient side. For patients, this is just the way it should be.

But I reflect back to my Dad. This case is such a triumph of modern medicine! In my Dad’s day, he would have had to do a pneumoencephalogram, probably, an excruciatingly painful Xray procedure where the neurosurgeon injected air through a lumbar puncture, the body was tilted this way and that, and the lesion outlined against air in the ventricles of the brain. Instead, we have an MRI with about half an hour of lying on my back, and exquisitely detailed pictures of every aspect of the brain, with millimeters of definition. Tell me that’s not Star Trek.

Then there is the surgery itself. Minimally invasive to the middle of the skull? The pituitary gland is like a pit in the middle of the cranium with the brain curled around it. Go in through the nose and operate on it with fiber optics and microscopic controls with a TV set enlarged to guide the instruments? Are you kidding me??? My Dad would have sawed off half my skull, I guess, looking for the pit. This has to be Star Trek, not earth in the 21st century. Except that it is.

So, as I say, modern medicine, space exploration, the Hubble, cosmology, string theory, not to mention securitization. I mean, think about it.

But beyond that, I take it personally. Look at what everyone had to do to be able to have Sandeep do this for me and in me. Look at what Mary Lasker and Lister Hill did when they started the NIH. Look at what Charlie Wilson did as a pioneer and as a trainer of others. Look what Sandeep has done to prepare himself to help me. Look at the time he took just with me. They did it all through the years so that they could do this for me, and for others like me. It is a person to person service. They did it for me.

Not that I particularly deserved it. I was lucky. I was the recipient of the favors of strangers – except for my father, who was not a stranger, and who also made his contribution.

And look at the people around me and the much-appreciated secondary gains. Succor and attention. Family around me and caring, friends, associates. I have to look at it all and be grateful.

I know the tendency for public health and preventive medicine to take a back seat to spectacular curative medicine, and that the greatest advances in health have been clean water, hygiene, and immunizations. But still, I’m hardly making the same contribution that these giants, including my doctors Mike Ries with my hip and Sandeep Kunwar with my tomato, have made and are making, not only in Neurosurgeryland and Orthopedicsland, but also in Cardiologyland, Oncologyland, and other Medicallands. It’s hard for me to think I’m making enough contributions. But I’ll just do what I can.

There was a study of righteous gentiles who helped the Jews during the Holocaust. Many of them had some experience in their lives earlier where someone had done something for them, more or less without obligation, just to do a good deed out of compassion. They knew how it had felt, and they could do the same in turn with some of these poor oppressed Jews. I think I feel the same way.

I am so grateful.

And finally, finally – it’s great to have personal relationships, and to feel individualized, but I am also part of a group. So, I don’t want to be just a name, I want to be a number! I want to be Kunwar pituitary adenoma patient #2,134! Come on, give me my place in the starry kingdom of Neurosurgeryland! I want my number!

Budd Shenkin

Visiting Africa

VISITING AFRICA

I’ve been away. On a big trip to East Africa, Kenya and Tanzania by way of Emirates Airlines and Dubai – long live the Dubai Mall! Big, lots of good stuff for people who like fancy stores and fancy stuff, and on the bottom floor I could buy a lithium battery to bolster Ann’s light for her Kindle for 3 bucks. It’s nice to have Arabic dress around, real people who just happen to dress that way, and Pakistanis who drive the taxis and remind us it’s only 3 hours to Pakistan and Afganistan, whereas it’s 15 hours to the U.S. They have lots of money, so they get to choose what lifestyle they want. They choose Arab dress, but it looks like they choose Western stores and goods. They had lots of money to make a Dubai first class, uninhibited by the restrictions of taste. Hoo-hah!

Anyway, that was our stopover before and after Africa, where I had been aching to go for years, but we went elsewhere on cruises and such, but then Ann said, if we don’t go now we’ll never go so we did. With trepidation. What if we get sick. What if we can’t take the rigors of a trip like that. What if. We needn’t have worried.

The hardest part was the packing. Since we were going on safari (Swahili word), we were restricted to one 33 pound small bag apiece, since we were flying on many small planes. We took weeks to get ready. I had to buy shoes, and thank goodness for my shoe guy Cyrus. I called him and he said I needed all terrain shoes, that’s what people going to Africa wore. I went there and he gave me no choice, just fitted me to the shoes he chose and I couldn’t be happier. If someone knows best, all you have to do is listen to him. Not too heavy, laces around hooks, OK!

Several trips to REI, mosquito repellent shirt. The company, Abercrombie and Kent, sent us flashlights that had bright white light, just after we bought mini.-flashlights at Ace. We took the free ones (well, considering the price of all this, not quite free) and were very happy. We used them in our tent cabins at the four lodges we visited, and going to dinner with our askari’s our guardians, who were unarmed, but I guess they knew how to shout at animals that happened our way.

We went on lots of game drives, in open and closed land rovers, looking for and finding game. We were mostly just alone with our driver/guides, or sometimes with others, but always very private, nothing like the tour buses from cruises. Very knowledgeable and very lovely people. We saw tons of animals, starting with zebras and giraffes, which seemed to hang together a lot so the giraffe could spot trouble from on high and warn the band. Giraffes walk with two left feet and then two right feet strides, so they aren’t too fast. But their kicks can kill a lion. We saw baboons warning others from trees about an approaching lion pride. We saw a pride of lions stalk and kill a wart hog, a half hour of stalking and about 5 seconds of jump and kill, after which the other four warthogs wondered what had happened to Henry.

But the animal most admired by our guides was probably the impala. Impalas hang together, but in two different groups. The guides would say, look, there’s the boy’s club or the bachelors club, where all the males are. And close by would be the harem with a couple dozen females and one male, who would be their consort for a few months. They guides would chuckle in admiration and say, he’s very tired. And chuckle again. He was their idol.

One afternoon at the Maasai Mara, where we had a beautiful cabin on the banks of the river where hippos soaked all day and night and made their noises so they sounded about 20 feet away, Ann took a rest and I went for a walk with my guide Richard. We walked through grass and by trees and he waxed eloquent about what was what and what did what. Who knew ebony trees were so skinny? An impala admirer, he had two wives and aspired to four, which was a pretty common aspiration. I couldn’t help thinking that their admiration for the chosen impala consort and their own aspirations were connected. His wealth was counted in cattle, which is common for tribes in Africa. I had studies the Nuer of Sudan in college, and the Dinka, and they were the same. We found hippos and some crocs on our walk, and talked. Talked a little about wives, were just together mostly, taking a walk. Took pictures of each other at the hippo pool.

As we walked I said he was a great walker, and I told him I was older but I was keeping up with him. He said, you are old, but you are strong. I guess that was true. I asked him how old he was and he said 37. Then he asked me how old I was and I said how old do you think? He looked, sized me up, and said 45.

So I said, actually, I’m older than that, I’m 69. He was amazed. He looked at me with wonder. He said, how do you do it?

I looked back at him, drew closer, and said, “One wife!”

He giggled and hit me on the arm and we had a fun time and walked home.

Budd Shenkin

The Re-segregation of health care

This is very sad. Just as US wealth is being increasingly concentrated at the very top, health care is being re-segregated at the very bottom. The segregation of facilities is primarily by wealth, and then secondarily by race, because that is the way wealth is distributed.

In the beginning, say the 1940’s when my Dad started practicing, the middle and upper classes received their health care in private offices and private hospital rooms, and the poor received their care in public clinics and hospital wards. My Dad told me about it. Back then there were fewer doctors, fewer medicines, fewer procedures, much lower cost, less health insurance, and no Medicare or Medicaid. My Dad and others like him felt a social responsibility - plus there were training needs – and hospitals functioned more for public service rather than for profits. My Dad served at PGH, Philadelphia General Hospital. He pronounced “PGH” with a tone I couldn’t identify, and maybe it was reverence. “This is what we did at PGH,” he said. He was nostalgic. “We treated the patients the same as we treated our private patients,” he said. “We took a day or a half-day a week and worked there for free. It was an honor to be chosen to work there.”

By “the same,” he didn’t mean the same dignity and convenience, but rather the same basic medical care. The clinics were big and impersonal, the ward beds were like you would see on M*A*S*H, no frills, but the treatment was good. The doctors and hospitals didn’t get paid, they just did it.

But of course everything was different back then. I suppose noblesse oblige worked for those times. Poor people were grateful to get the care and there were no complaints about dignity, and few about racism. Different days, to be sure.

But in 1965 Medicare and Medicaid were passed and that changed everything. Medicaid covered many of the poor and gave them to right to be seen in offices rather than clinics, just like middle class patients, if the practitioners agreed to be paid by Medicaid. Most practitioners did take it at the beginning, when payments were fairly competitive. So did most hospitals, which improved their bottom lines. Public clinics and hospital wards persisted, since there were still relatively few doctors and hospital habits were hard to break. Even into the 1980’s at the largest of my local hospitals, private patients on the maternity wards had private or semi-private rooms, and most Medi-Cal patients were placed in larger wards with only curtains walling off the beds from one another. Yet even those larger wards vanished by the 1990’s. Still, the staff sought to place culturally similar patients in semi-private rooms (which was a good thing, I think. Picture yourself as a new mother with a roommate who keeps the TV on all the time, and is on the phone all the time, etc. Cultural clash.)

Coverage vs. Access

But then what happened is what always happens. The money devoted to care for the poor, governmental money, was whittled down. The original fees for doctors weren’t too bad – but they never changed as the years went by and inflation occurred. Is a separate program of health insurance for the poor equal to health insurance for the middle class? Maybe at first, but in time it won’t be. Separate is just never equal.

Gradually, the diminishing fees pushed more and more doctors out of Medicaid. Government didn’t acknowledge this movement, it claimed increased coverage, as more patients qualified for the program. But “coverage” does not equal “access. Here in California, the worst case scenario in the United States, we have extensive “coverage,” but the Medi-Cal fee schedule calls for about 35% of Medicare fees – which many think are already too low. Try to fathom that -- 35%!

Alameda County

Here in Alameda County our primary care pediatricians have been protected to a certain extent. Our Managed Care Medi-Cal, contract allows pays our pediatricians at maybe 80-85% of Medicare rates. These are low rates, but just about manageable to be able to keep serving our Medi-cal patients. At our practice we started with Medi-Cal patients as most practices did, but then instead of abandoning them as we attracted more private patients, we kept the Medi-Cal patients and just got bigger. This is what Medicaid envisioned, I think – one class of care. It takes some forbearance on the part of our private patients, since there are cultural differences that can grate as classes mix, but on the whole, this being the Bay Area, we have been successful.

What do patients want? The Alameda County Medi-Cal population has voted with its feet. Despite an extensive clinic system, 65% of Medi-cal patients choose private practices as their primary care practitioners. This didn’t just happen. The planners of Medi-Cal Managed Care mandated a two-plan system for each county, so the doctors had competitive plans to contract with. It also took a very public spirited Director of Health Care Services, David Kears, who believed in primary care, and believed in giving the choice of provider to the patient, and did not take the usual public health department bureaucratic route of trying to steer all the patients and all the money to their own clinics. And in addition, we primary care pediatricians got together and negotiated ourselves a decent deal, we didn’t just take what they gave us. As a result, many private pediatricians have stayed in Medi-Cal, and the original intent of Medicaid seems to work here locally in pediatrics.

Re-segregation

But it’s not going to last. Time, finances, and the inexorable drive to discriminate is catching up with us. Nationally, the Affordable Care Act (ACA) grants $13 billion to the clinics. There will be a mandate for 2013-2014 to pay 100% of Medicare for certain primary care visits, which might actually stay in the bill, we’ll see, but that may or may not apply.

Locally, the current Department of Health Care Services and the Medi-Cal managed health care plan tied to the county, the Alameda Alliance for Health (AAH), are applying to the Feds to become a County Organized Health System (COHS). They dress up this proposal as “saving money,” although exactly how this would happen is mysterious. They say that if there were a single system they could “coordinate care” better, although the only concrete proposal to do that is to hire more administrative staff. Essentially, the COHS application is an application for county monopoly over the Medicaid program.

We have met with AAH and the County. It’s pretty clear – they want more money and power, they will increase their administrative staff, and they will reduce our payments. Like every other county government, alas. Currently, as we pediatricians negotiate with AAH, we can sign with them or leave them and switch our patients to Blue Cross Medi-cal. With a COHS in place, our new choice will be to sign or leave Medi-cal completely. That’s what a monopoly looks like.

So, add it up -- more federal money for the clinics, more money for the health department, and less money for the private doctors. Most private doctors will bolt; they will have to. The private doctors who remain run offices that you would not want to patronize. “Coverage” will once again not equal “access.”

Once again, the poor will be served in clinics, the middle class in offices. Idealistic liberals, supporters of the clinics -- socialists, really – imagine that the clinics will actually give better care than private offices, no matter patient preference.

But you have to know that their dreams ain’t gonna happen. If you think for one minute that poverty medicine will be superior to private medicine, think again. What will happen is that care will be re-segregated by income, and hence by race as well. This will be congruous with the increasing inequality of wealth and income of the last 30 years as we Latin Americanize our social fabric. I wonder what my Dad would think.

It is such a damn shame. I can only hope I’m wrong, and that things will turn around. We are fighting the COHS proposal, and maybe it won’t happen. I would so hate to see our patients who have come to our office these past decades disappear to the clinics.

Here’s hoping!

Budd Shenkin

Enter the Feds

We serve Medicaid patients. Always have. It was fairly traditional in our area to start a practice with Medicaid patients and gradually withdraw as the private patients built up. We took a different tack and just kept them and added practitioners. It fit our social responsibility agenda, and I don't think we lost money on it. I think we still manage a very modest margin.

Part of what we do is give vaccines. There, we really lose money. There is no mark up on the Vaccines For Children program "free" vaccines, and the immunization administration fee is only $9.50. By contrast, for private patients we have a markup on the vaccines of a certain percent that covers our overhead for ordering, storing, keeping track of temperature, etc. etc. It's considerable work, and for the Medicaid patients, we get nada for this. The official Medicare values for vaccine administration would be $25 for most vaccines. So giving our Medicaid vaccines is a considerable loser for us.

The problem with government is that you agree to treat Medicaid patients at a very reduced fee and they treat you like a criminal. We just got a notice on Monday that the Inspector General - must be the Feds, I don't yet know for sure - will be coming to our office on Thursday and has a list of 24 policies, temperature logs, etc., that they want on a CD to give to them.

"Will be coming," no "May I." No explanation. No niceties. No nothing. It's a wham-bam without the "thank you, M'am."

The Feds! I'm going to tell them to visit the land where the sun don't shine. Twenty-four items! For the privilege of losing money.

Honest to God. These people.

Budd Shenkin

The Best Ride to the Maui Airport

Sometimes things just pop out of the ground, it seems like. Our friends the Moes were going to take us to the airport to go home from Maui, but we told them the wrong time to pick us up, so we improvised and walked across the street to the Kia Lani Hotel to catch a cab.

Boy, did we catch a cab. Our cabbie, Jack, was an older guy with white hair in a ponytail and a droopy white mustache. He told us as we left that he liked driving a taxi and was doing it on this Saturday so he be off next Saturday to watch an NBA playoffs double header.

His accent seemed familiar, so I asked him where he came from.

“Outside Philadelphia,” he said.

“Where?” I asked.

“Havertown,” he said.

“Where did you go to high school?” I asked.

“Haverford High,” he said.

“I went to Lower Merion,” I said.

Jack observed that Kobe had gone to Lower Merion, and I assured him that Kobe had learned that crossover move as a legacy from yours truly.

So here we were, 5,000 miles from our mutual original homes, running into each other by chance and finding we went to adjoining, rival high schools. And it seemed that we were both basketball fans, which is not so strange if you come from Philadelphia. (One of my college roommates from Braintree, Massachusetts, didn’t believe us about Philadelphia basketball mania until he came to Philly for a holiday and saw a hoop behind each house and kids walking down the street bouncing a basketball. He capitulated.)

So we had the best time ever talking Philadelphia basketball to each other, Ann watching and listening bemusedly. What is reminiscing about basketball? It’s really a panoply of names, each conveying the physical image, the moves, sometime the games, and an intensity of feeling. Plus personal encounters if they occurred. Talk to me about Philadelphia basketball and it won’t be long until I mention the great Guy Rogers, my hero. How I loved Guy Rogers from the time he was a sophomore at Temple, and then into the pros with the Warriors! God, I thought, I wished, I truly believed he was better than Bob Cousy!! I wrote my greatest freshman year paper “Mr. Basketball, or Why I Hate Bob Cousy” and to this day am convinced that Cousy was ordinary, and that adding Russell to the Celtics was the crucial move, and other guards could have done what Cousy did.

But I digress. I did not leave out in my conversation with Jack that I was in a car on a pretty summer day with Larry Ring when Guy Rogers came off the court at Narberth Playground and said to us, “I want to buy that car!” My God, I said, that’s Guy Rogers! A signature moment of my life. And Jack knew about Narberth Playground, he had played there, and it was just three blocks down the hill from my house.

First Jack and I covered the pros – names, names. Arizin, Johnston, Wilt of course, even Joe Fulks. He passed my test – he knew who Fulks was, and knew he had a jumper. We hit the Big Five college names, every one. Temple, Penn, LaSalle, Villanova, St. Joe’s. Rogers, Lear, Van Patten. Ernie Beck, Sid Amira, McCloskey. Tom Gola. Walli Jones. Goukas and Dr. Jack. Stories, moves, years.

We even hit high school. The Chester teams – he said “Jerry,” I said “Foster, and his brother Billy.” Granville Lash and Emerson Baynard. I told him how we beat Chester when Bob Campbell hit 8 of 10 outside shots before he got a concussion. Mark Dumars from Western Pennsylvania and the 1958 high school state finals.


And then the unbelievable finale. His late ex-wife came from Reading. “Reading,” I said, “Home of my first girlfriend, and the home of beer, pretzels, vice, and Albright College.” “Actually,” I said, “The guard on our high school team went to Albright and played ball, Norman Ruttenberg.” Now, this is the most obscure fact in the known world. But Jack responded, “Ah, Dr. Norm!”

So, as I say, 5,000 miles from home, two very different guys, him from Lackawanna College after a year on an oil tanker to make some money, me a Harvard doctor, and here we were, best friends. We did sneak in some personal stuff. My tenure with the Harvard JV’s and our 23-0 junior year when we beat our own varsity three out of four times. His basketball scholarship to Penn if only he could have qualified academically. Not to mention that he lived in an apartment house a floor down from Billy Cunningham and would run with them if they were a man short. His two artificial knees that are working great. My three knee operations and artificial hip. Hey, the ravages of war.

We reached the airport and he said how short the trip had been, and he said it was the best ride he’s ever had. I said “Me, too.” We took his card. I’ll call him. Maybe we can go to the Maui Invitational together. It would be real fun.

I knew Ann loved it. So I asked her, “What were you thinking while we were talking.”

She said, “I was thinking, when is Budd going to stop talking with taxi drivers?”

She’s so funny.

Budd Shenkin

Was Hank a Dinosaur?

I have to say I'm absolutely struck by the heartfelt comments on my post about Hank. So I'm wondering, was Hank a dinosaur?

That is, he was in private solo practice. He was with a couple of groups before he went solo - don't know what the story was there, but he finally found himself in a small office by himself and had never been happier. Nothing between him and his patients, except insurance, but he didn't grouse about that.

Medical sociology, mostly Eliot Friedson in his great tome Profession of Medicine, looked at groups of doctors, mostly large groups in New York. He said that the more you are in a group, the more you look for consensual validation from your peers - that is, other doctors - and the less you look to your patients to validate your work and you as a person. I would imagine that the more administration there is, the more you look for validation from the administrators, the more you want to be like them (every doctor I know thinks that administrators have a sweet deal - little do they know). So with larger institutions patients are less patients and the more customers or even consumers.

Maybe I'm wrong. Maybe when a Kaiser doctor leaves the scene for whatever reason, patients feel bereft. Or maybe they shouldn't feel bereft, so personally deserted. Maybe they should feel that there is another one just behind him or her, waiting to take their place. I remember in Sweden when I would talk to people about the impersonality of the polyclinics, some of them said, but isn't that what you want, objective opinions?

But for myself I can't think that medicine should be anything but a real person to person enterprise. Our group, Bayside, is large by Bay Area standards - about 35 clinicians in 10 offices. But the offices are small, intentionally, not one stop shopping but rather pearls on a string. I think my job is to make sure we retain the ideals that Hank personified. We'll see if it's possible - I think it is. The culture comes from the top, they say, and I think everyone knows where I stand. With the dinosaurs.

Budd Shenkin

Welcome Back Budd

I have been neglecting my readers, and myself, by not posting lo these many weeks. Unlike a columnist, I don't have to churn them out and can lay fallow at times. I hope that's what I've been doing, fallowing. I've been distracted. Two trips to Chicago for AAP meetings, losing my wallet (and having it found) on one trip, losing my favorite belt in the scanning machine when I forgot it and discovered the fact too late when my pants were falling down. Many activities at the Goldman School of Public Policy where we hosted former Senator Bob Graham last week, and then health economist and Obama advisor David Cutler - first time I met him. Losing my Kindle. Worrying about good friend Bob with two heart attacks, my good friend and neighbor obstetrician Hank, who delivered my step-granddaughter with a midnight house call, with recurrent melanoma. As my friend Michael says, as you get older, there is no Yellow Brick Road, you just keep doing what you have always done, coping. Sigh.

Also, there is the tyranny of success. I have been so pleased to get positive responses about my blog from people I respect that I don't want to pollute my product with mediocre posts. Easy enough to do. It can be a killer. One of our employees, after years of underproduction, met with our new Administrator and began to do really well. They then went out with anxiety, and their stupid doctor recommended rest - like a pill, rest. Idiot! The employee finally does well and collapses with anxiety? What about some counseling to make it possible for them to continue to do well, and not worry if they can keep it up? Doctors. Kaiser. Idiots.

OK, so with this prolonged intro, here's my post on health care, my now and forever topic.

Our system of health care sucks. Everyone knows that. Here is another detailed complaint from a primary care doc at the Mass General (sine she is at Mecca, anything that happens must be someone else’s fault.) Then a comment from my friend pediatrician Jon Caine, and finally trenchant comments from me.

A Waste of Money

By Katharine Treadway

Last week, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked: almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow up and management of what were, for the most part, stable conditions. Thus my nurse sent her to Urgent Care, a unit set up so that patients can be seen quickly for acute medical problems rather than being sent to the emergency room. The necessity for such a system has developed gradually as the burden of prevention, chronic care, documentation, and paperwork has eroded the flexibility of many internists to squeeze in the extra patient who has an acute problem. The result of this system is that paradoxically, I see my patients when they are well or stable and urgent care sees them when they are sick; the reverse of what should happen. The cost of such a system can be significant, as this story illustrates.
The nurse practitioner who saw my patient in Urgent Care sent her to the emergency room for evaluation of a transient ischemic attack (TIA, characterized by passing stroke-like symptoms) despite the fact that a symptom lasting 1-2 seconds does not fit any definition of a TIA. Once in the emergency room, she was seen by the medical service and then the neurology service who, not surprisingly, ordered magnetic resonance imaging tests which, also not surprisingly, were entirely normal. She was sent home after several hours with instructions to follow up with her primary care physician.
I saw her a few days later and carefully reviewed her history which confirmed the story of a 1-2 second white-out of her entire visual field bilaterally which resolved with complete visual clarity in the time it took to blink. She had no preceding symptoms: no heart palpitations, no lightheadedness, no other focal neurological symptoms. Except for a burst of anxiety, she felt entirely well after the episode and has remained so.
I thought about the close to $10,000 that had been spent ruling out a serious cause of her symptoms. If I had been able to see her, would it have made a difference in her management? I believe it would have for two reasons. After listening to her story in detail, I was confident this was not a significant neurologic event. Because she knows and trusts me, I was able to reassure her with my opinion (which interestingly the normal scans had not been able to accomplish). But equally importantly, because I knew her well, I was willing to take responsibility for my decision. One of the hallmarks of being a primary care physician is to be comfortable with uncertainty. We learn to trust our clinical judgment and not jump to ordering expensive tests “just to be sure.” It is hard to accept the responsibility of decisions when the patient is unknown to you.
It is clear that we need to redesign primary care so that we can see our patients when they are sick, not just when they are well. The medical home is one such model and there are undoubtedly others but whatever the design, it cannot be assumed that medical personnel are interchangeable. The knowledge of a patient gained over years coupled with the trust such a relationship builds for both the doctor and the patient are essential components of cost-effective medical care.
Katharine Treadway, MD is a primary care physician at Massachusetts General Hospital who teaches at Harvard Medical School.
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Jonathan Caine MD says:

The sequence of events you describe was completely predictable once you made the decision to “turf” the patient to the Urgent Care Center. What your patient experienced was a sequence of defensive medicine decisions. First, the NP was not able to correctly diagnose the patient was not having a TIA. (Those bureaucrats who believe that NPs will save the “system” money because they are paid less for providing services, please take note.) She in turn “turfed” the patient to the ED, who then “turfed” her to neurology. Neurology did what neurology consultants do, that is, order MRIs (and occasionally EEGs). The fact is no one gets sued for ordering too many tests. The number one cause of malpractice suits these days – failure to diagnose. Would the medical home model have prevented this as you surmised? Doubtful. You could have had the highest level of NCQA Certified Medical Home, but if you were fully booked and couldn’t see the patient that day the same outcome would have occurred. If you were truly confident in your impression that she did not have a TIA, you never would have referred her to the Urgent Care Center in the first place. So, your decision was defensive medicine as well. Until we have legitimate tort reform in this state these types of cases will continue to occur on a daily basis in Massachusetts.
Jonathan Caine MD, Pediatrician

• Kate Treadway says:
You are absolutely correct about the problem of defensive decision making and that is the point of my blog – that, as primary care doctors who know our patients, we are much more willing to accept responsibility for these types of decisions. My nurse sent the patient to urgent care without my input so I was not part of that decison making process. However, I also heartily agree that tort reform is absolutely necessary if we are to change medical care and medical costs. Thanks so much

And now, breathless reader, my own comments:

She thinks the problem is "the system," a vague designation. You, Jon, think the problem is defensive medicine. I agree. But although both are correct, I think we should look further.

First, let's not forget incompetence. Was the NP generically over-matched -- that is, no NP could make this diagnosis, and only a doctor could -- or was she as a professional not up to the job?

Then the ER - why could they not deal with this? Not sharp enough?

Then the neurologist. Is the primary care doc smarter than the neurologist in his or her own specialty? Or were they mindless?

So, yes, certainly defensive medicine and the fear of lawsuits pressure all of us in practice. But then there is competence or the lack thereof and courage of convictions.

However -- having said that -- the "system" will not reward any of these professionals who saw the patient for their abstemiousness. No way. So why try if your only reward will be your own knowledge of what you have done? It's not enough.

But then, why has this primary care doctor so overbooked her day that she does not have the capacity to see an acutely ill patient? Why has she set up her practice this way? She blames others, but why? We have the same mix of pre-scheduled and acute patients in pediatrics, and we make sure we have enough capacity every day to see anyone who calls in.

Perhaps the issue is payment. Because we build in the capacity to see patients who might or might not call, we sometimes have unused capacity. We therefore make less money than we might otherwise. If primary care adult doctors had higher payments and thus had more money to play with, perhaps they could do the same thing.

But one still has to ask, why is her practice set up this way, with an urgent care center somewhere else? Wouldn't it make sense for her to have a group practice where they had an urgent care center right on their premises? Wouldn't it make sense for her to employ some nurse practitioners or physician assistants to see some of her regular patients for some of their visits, allowing her to see some of the more difficult patients -- our patient in question -- when warranted? It would be better medicine, and the partners in the practice would make a little more money.

Our physician corps does have many entrepreneurial members, and being entrepreneurs, they often look for the biggest payoff, which is available in areas other than primary care. The entrepreneurs thrive in areas with surgical interventions, or radiological interventions, or some such -- that's what our system pays for. But still, our primary care physicians can build systems that serve patients better and make themselves a little bit of money in the process.

So, yes, it's the system. But this primary care doc let's herself off too easily. Better to ask, "Why have I not set up my practice so that I can serve my patients better?"


And finally from Jon:

“I agree completely that the problem lies with the doctor herself and the way she is scheduling her office visits. I sort of implied that with the term "turf". I didn't want to continue to bash her so as not be accused of assault.”


Budd Shenkin

Dcotors and Nurse Practitioners

There is a vigorous discussion in medical care organization policy circles on the role of physicians, and the role of “advanced practice nurses” and physician assistants. How much can the role of the doctor be played by these so-called midlevel practitioners? In practices headed by physicians, midlevels already thrive. But the recent ACA legislation has succumbed to the nursing lobby and granted money for independent nurse practitioner clinics where physicians would not be present.

I present here a discussion from our American Academy of Pediatrics administrative listserve that I found interesting. You can’t make these arguments persuasively without looking closely at what actually happens, and what people in the field find. In this listserve exchange we hear first from Seth Kaplan, pediatrician in Texas, on his day where he had to exercise a great deal of his physician prowess. What would a nurse practitioner have done with these patients? Jon Caine of Massachusetts answers puckishly. Finally, David Horowitz of North Carolina makes the case (which I have shortened) that some docs couldn’t have handled this case load as well as Seth did, but that some nurse practitioners could have given it a pretty good shot. David points out, rightly, that a person is not totally defined by his or her training.

First, Seth:

There's been a lot of talk on the listserv about the possibility of mid-level providers replacing general pediatricians over time. I'm sure most of you have had similar days, but this is a synopsis of my day today:

The normal well checks and sick checks, dominated by gastro and a febrile illness without much of a source, with fevers to 103-104 lasting 4 to 6 days.

A 4 month well check with a very depressed mom.

A new sick patient with fever, who, oh by the way, has adrenal insufficiency, growth hormone deficiency, thyroid dysfunction, and some unidentified underlying disorder.

One of the kids with high fever for several days who had some small lymph nodes and mom has been convinced he must have cancer and will no leave without getting a cbc done and the cbc has an ANC of 700 (probable viral suppression - kid otherwise looks good, but we will be rechecking counts).

An 11 year old with poorly controlled asthma due to parental non-compliance and poor understanding who I ended up having to admit.

A well 7 year old with the "oh, by the way, I'm concerned about inattentive ADD".

A teen brought in for concerns about weight loss, "not looking well for 3 months, does he have diabetes?"

A child with arthyrogryposis with growth patterns that are difficult to make heads or tails of.

The sick kid with gastro amongst many who only came in because they wanted Zofran, but their exam sure seemed a lot more like appendicitis and it took 20 minutes to convince the mom that we really did need to image, check labs and get a surgical consult despite the fact in would involve a needle stick and maybe an IV, because "if she doesn't have appendicitis, I don't want her unnecessarily stuck"

The new well visit with an adopted kid who is a victim of sexual abuse both by her birth parents and multiple foster families, who exhibits signs of PTSD and major behavioral problems.

One of the kids with the high fever thing whose mom took him to Minute Clinic after school 3 days ago because "it was right next door" and the NP told them that "she was going to stop taking the temperature because it went up every time they took it and if it is above 103, we have to refer him out."

All of this in ONE DAY. Would love to see a "mid-level provider" handle it all.

Don't really have a question, just venting and thinking that we do is awfully challenging. We should be proud to be general pediatricians and continue to fight for our role in the healthcare system.

Seth D. Kaplan, MD, FAAP
Frisco, TX

Now, Jon’s reflection on Seth’s day (note the increased costs the nurse practitioner’s actions would entail):

No one is saying that PNPs will be effective or even cost-effective replacements for pediatricians. But, as long as Scope of Practice laws continue to be passed allowing independent practice in states where the politicians "think" they will save money, it will continue to progress. How would a PNP in independent practice handle your day?

1. Normal well/sick visits - Piece of cake
2. Depressed Mom - Refer to psych
3. Multiple Endo Pt - Refer to Endo
4. Neutropenia - Turf to Tertiary Children's Hospital ED for workup
5. Asthma Exacerbation - Turf to Local Hospitalist or Children's Tertiary
6. ?ADD - Refer to Pedi Neuro - 4-6 month waiting list
7. Teen with weight loss - Back to Children's Hospital ED
8. Arthrogryposis - Refer to Genetics & Endo
9. R/O Appendicitis - Give Zofran. "If pain worsens go to ED".
10. PTSD - "Call your insurance plan for psychiatrist who is participating in their closed panel".
11. Minute Clinic kid with fever and shockingly no antibiotics - Rx: Antibiotics
12. Lunch Break

Jon Caine MD

Tongue somewhat firmly in cheek.

A quick note from Jeff Couchman of Arizona:
Actually, I think many of the people who are changing scope of practice laws actually ARE saying the PNPs will be effective and cost-effective replacements for pediatricians…
Jeff Couchman, MD
And finally, from David Horowitz (edited):

I have worked with a PNP who could handle all (all right, most) of those kids appropriately. I have worked with real board certified pediatricians who would have handled this list the same way listed (by Jon), or even worse, attempted to treat the complicated kids and do it wrong. IMHO, one of the key attributes of being a good doctor or provider of health care is to know what you don’t know but know where to find the answer to those questions you don’t know. The bad docs I’ve worked with didn’t know that they were doing the wrong thing for their patients. All of the NPs I have hired have freely come to me with questions when they didn’t know the answers and asked very appropriate questions. That is because the structure I provided in my office meant that the NP was never there alone.

The question of the role of NPs is a lot more complicated than “should they replace us”. The first PNP I hired was one of the smartest people I’ve ever met. She was competent enough to work sick call on evening hours by herself and I never felt uncomfortable because I new she would call me if there were issues. She did more work in the running of the office than many hired doctors I have had. On the other hand, I have had an FNP work in my office who I felt I had to look at every ear to confirm if it was a real otitis or not.

…(It is important to note that) not all NPs are created equal and there are several training tracks: Pediatric, Adult, Family, and Neonatal. …There is no doubt in my mind that the ONLY qualified NPs to do any serious pediatric work are PNPs. Adult NPs have no training in kids at all, and FNPs are similar to Family Practice doctors in their training, and I see little to no role for them in seeing quantities of children.

(But) as good as some PNPs are, they are not doctor replacements, they are doctor extenders. While the laws may be structured so that the doctor doesn’t have to be physically present in the building to provide supervision (I am thinking of rural health centers here, not Minute Clinics), there MUST be a supervising pediatrician immediately available by phone. I am against totally independent practice without any MD supervision and this aspect is one area to focus our attention on legislation. I can also see different rules for rural health clinics where there is a lack of other qualified pediatrician services as defined by the government, and Minute Clinics, which are totally different in purpose and orientation.

David Horowitz