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
Sunday, February 13, 2011
Tuesday, February 8, 2011
My Son Peter - A Reminiscence
When Peter was small, he was really small. He was born small at 35 weeks gestation when Ann had HELPP Syndrome, which had yet to be described in the literature, so as her blood didn’t clot and her BP was up and her liver enzymes were up and she was very sick and went into labor at 35 weeks, we all weren’t sure what was happening. It turned out all right and Peter more than survived. But he was small. Today he is just a bit shorter than I am and all muscle and very athletic, but when he was younger he was small.
But smart and with an emotional IQ of 150 from the day he was born. Here he would be, about three feet tall, standing by the door and looking straight up at our friends and say, “How was your vacation?” People would say, is that a little kid, or is that a midget? And they would leave saying, “That kid is going to be President.”
But before that, Pete was small and very verbal as a three year old. Having older sibs was a big help because he acculturated readily, and made the expressions of others his own. He taught himself to read by taking baseball cards and finding out where they belonged in the scrap-book by comparing letters in the names. He had no hesitation in parroting. One day he turned over the telephone (let’s all date ourselves), saw the symbol and said, “AT&T – The Right Choice!” Big mouth, my parents would say.
So Ann had passed the bar, worked for a firm she didn’t particularly like, then went to work for a small firm she did like, and we invited the youngest partner and his wife over for dinner, and some lawyer patients of mine that I liked, and we had dinner. It was a nice time, and we were on our good behavior, as one would be in that circumstance. A nice dinner and nice talk as Ann and I tried to find ourselves in our new lives as young professionals.
As the dinner came to an end, who would provide the coup de grace? Peter, of course. So down the stairs he came, our little verbal cherub, as the dinner broke up and we all headed for the door. “Here’s Peter!” we exclaimed, and started to introduce him.
Pete walked down the stairs and surveyed the situation with his 150 emotional IQ. We were so proud, he was so darling. Then he spied in our front hall – we had five kids, after all – a parked bicycle. Well, that happens. But Pete was no doubt conscious of how this violated the image of the young lawyers. His visage clouded over, he became incensed, he approached the bike head on, he glared, he kicked the front tire, and with the impassioned heat of a violated host pronounced: “I told Brian to keep his fucking bike out of the hallway!”
I’m still laughing at Peter – and, I guess, at our little pretensions. I guess I could have sent it in to Reader’s Digest if it were a little less of a family magazine.
Budd Shenkin
But smart and with an emotional IQ of 150 from the day he was born. Here he would be, about three feet tall, standing by the door and looking straight up at our friends and say, “How was your vacation?” People would say, is that a little kid, or is that a midget? And they would leave saying, “That kid is going to be President.”
But before that, Pete was small and very verbal as a three year old. Having older sibs was a big help because he acculturated readily, and made the expressions of others his own. He taught himself to read by taking baseball cards and finding out where they belonged in the scrap-book by comparing letters in the names. He had no hesitation in parroting. One day he turned over the telephone (let’s all date ourselves), saw the symbol and said, “AT&T – The Right Choice!” Big mouth, my parents would say.
So Ann had passed the bar, worked for a firm she didn’t particularly like, then went to work for a small firm she did like, and we invited the youngest partner and his wife over for dinner, and some lawyer patients of mine that I liked, and we had dinner. It was a nice time, and we were on our good behavior, as one would be in that circumstance. A nice dinner and nice talk as Ann and I tried to find ourselves in our new lives as young professionals.
As the dinner came to an end, who would provide the coup de grace? Peter, of course. So down the stairs he came, our little verbal cherub, as the dinner broke up and we all headed for the door. “Here’s Peter!” we exclaimed, and started to introduce him.
Pete walked down the stairs and surveyed the situation with his 150 emotional IQ. We were so proud, he was so darling. Then he spied in our front hall – we had five kids, after all – a parked bicycle. Well, that happens. But Pete was no doubt conscious of how this violated the image of the young lawyers. His visage clouded over, he became incensed, he approached the bike head on, he glared, he kicked the front tire, and with the impassioned heat of a violated host pronounced: “I told Brian to keep his fucking bike out of the hallway!”
I’m still laughing at Peter – and, I guess, at our little pretensions. I guess I could have sent it in to Reader’s Digest if it were a little less of a family magazine.
Budd Shenkin
Sunday, January 16, 2011
The Great Steve Martin
I’ve always liked Steve Martin a lot, maybe loved him, not exactly putting me in a minority. Remember when he started? Everyone had a beard and was scruffy, but Martin looked like a regular button down guy with prematurely gray hair. “Why do you dress like that?” he was asked. “To be different,” he said, truthfully, with his trademark subtle irony, since of course the first scruffy guys wanted to be different, and then everyone else figured that was the way to do it. He was great, as everyone knew, that wild and crazy guy. My special favorite, the Christmas wishes monologue: (http://www.hulu.com/watch/116204/saturday-night-live-steve-martin-introduces-his-christmas-wish).
I had read some of this New Yorker articles. He could write! Then I read his autobiographical Born Standing Up. Great writing -- direct, vivid, truthful, excellent writing. The picture of him growing up seemed so authentic. He had worked so hard starting at the bottom. I particularly liked how he was different from me, since I was on the track of Ivy League, med school, etc., not just trying something you liked with no guarantee at all. Then I remember especially his recounting his triumphant one-man tour when every event was completely sold out. He trooped people out the door all together as part of the act at one point, amazingly. Then one day, he saw it. Way, way in the back of the balcony, there was an empty seat. He wondered if it would be filled a little later, but no, there was an empty seat. So I knew it was coming to an end, he said. His writing is so intimate that I felt I was his friend. That’s hard to do.
So, I just read his new novel, An Object of Beauty, which I think is just great. I’m prejudiced by loving him, but still, I think the book is great. Surprisingly to me, it reminds me of Richard Ford’s Independence Day, in which Ford’s protagonist, Frank Bascombe, is doing real estate, and the picture of the real estate business makes you understand what it’s like to be in that world. Ford said he hung around with real estate people a lot, just found himself doing it, before he wrote the book.
That’s what Steve does for the art-collecting world in New York. As an art collector himself he clearly knows the people and the business. As with the real estate business after reading Independence Day, I think I know a little something about the art-collecting world now, too.
I like the story, featuring Lucy Yeager, a very pretty girl who becomes upwardly mobile first at Sotheby’s, then with her own gallery, and who is not really likable at all. I read this the same week we saw The Social Network, which we liked, and which doesn’t have many if any likable characters at all. I found shades of sympathy with most of An Object of Beauty’s characters, but still, there was something in common with Social Network. Lust pervades both, money and sex, and at least in the book, beauty. The narrator, a guy who is a friend of Lacey’s and who becomes an art writer, is sympathetic. Some are more and some less sympathetic, and all are real, at least those in the constant trade winds of the art world. They either lust after art, or they are in the business of servicing those who have that lust. You will have noticed that the title is a double entendre, some lusting after art, some after Lacey, many after both. And maybe that’s almost the same thing.
What’s it like to be lusted after all your life, to be an object of beauty? That’s Lacey. She knows she is lusted after by most men she meets – that’s us, men! – so she uses it, and has contempt for those who continue to be used by it. Boy, does she use it. When she rides her bike with a halter top and shorts, she listens behind her for the metal clank of bikes crashing as, she imagines, boys and men are looking at her. I guess this is what many beautiful and sexy women deal with – it’s probably hard to do, to figure out who loves you and who is simply lusting for you. Most people probably feel, as with great wealth, I know there are problems, but I wouldn’t mind that challenge. At the end she has a long affair with an FBI agent, the only one she knows below her station, who she always calls “Agent,” and who she loves because he never tells her he loves her.
It’s interesting that Steve has this agent look at a painting he likes – his line is not art appreciation but following art theft, so if he likes something it’s from a very unprofessional view – and he tells Lacey it might be symbolic, explains what symbolic is (thank you, says Lacey), and then says the sea is reality, the sky is the dream, and art is trying to connect one to the other. Sounds like Steve to me.
Steve writes really good sentences. He writes with structure. We hear it referred to that Lacey came into money, and we think, she did? Did I miss exactly how that happened? But it pops up later. The story doesn’t bog down for a minute, and I like his short chapters. I didn’t want the book to end, but still, when I would look ahead and see that it was only a couple of pages, especially since I’m having some trouble with my eyes, it would be a relief. Steve might have started as a showman, but he is a writer, in every good sense of the word. He is a very good writer, and I’m so glad he is.
All of which reminded me of my brush with the art world. It was 1970 and I was in graduate school at Berkeley, my first wife Mary Jane was an undergrad at Mills College, and we lived at the corner of Arch and Hilgard, just a few blocks walk for me to school. She brought home a fellow student one day who lived just a block up the hill from us, a young lady who dressed in a peasant-type dress, I guess it was, and whose chest was very alluring. I was 29 years old and had as much testosterone as most guys that age, probably at the higher end of normal. Truthfully, I just couldn’t get over her chest just below the scoop neckline as we stood there. She was recently married to a guy who I met probably a few days later, it’s hard to remember the details, but I do remember it was hard to think of anything beyond this young woman’s chest, very hard. Anyway, I guess she and her young husband wanted to be friends. He was a nice enough guy on the small side. He was called Dicken, which in German meant little Dick, because he was junior to his father, whose name was Richard.
So, as part of getting to know each other, they said that Dicken’s father was an artist and did I want to meet him and see his studio? I pictured walking up to his house nearby, looking at the studio, who knows what boring stuff I would be faced with. So I demurred, we never became friends with this young couple, life went on, I never met the father. Face it, I was distracted.
And so it was that I never met Richard Diebencorn.
I am such an asshole.
Budd Shenkin
I had read some of this New Yorker articles. He could write! Then I read his autobiographical Born Standing Up. Great writing -- direct, vivid, truthful, excellent writing. The picture of him growing up seemed so authentic. He had worked so hard starting at the bottom. I particularly liked how he was different from me, since I was on the track of Ivy League, med school, etc., not just trying something you liked with no guarantee at all. Then I remember especially his recounting his triumphant one-man tour when every event was completely sold out. He trooped people out the door all together as part of the act at one point, amazingly. Then one day, he saw it. Way, way in the back of the balcony, there was an empty seat. He wondered if it would be filled a little later, but no, there was an empty seat. So I knew it was coming to an end, he said. His writing is so intimate that I felt I was his friend. That’s hard to do.
So, I just read his new novel, An Object of Beauty, which I think is just great. I’m prejudiced by loving him, but still, I think the book is great. Surprisingly to me, it reminds me of Richard Ford’s Independence Day, in which Ford’s protagonist, Frank Bascombe, is doing real estate, and the picture of the real estate business makes you understand what it’s like to be in that world. Ford said he hung around with real estate people a lot, just found himself doing it, before he wrote the book.
That’s what Steve does for the art-collecting world in New York. As an art collector himself he clearly knows the people and the business. As with the real estate business after reading Independence Day, I think I know a little something about the art-collecting world now, too.
I like the story, featuring Lucy Yeager, a very pretty girl who becomes upwardly mobile first at Sotheby’s, then with her own gallery, and who is not really likable at all. I read this the same week we saw The Social Network, which we liked, and which doesn’t have many if any likable characters at all. I found shades of sympathy with most of An Object of Beauty’s characters, but still, there was something in common with Social Network. Lust pervades both, money and sex, and at least in the book, beauty. The narrator, a guy who is a friend of Lacey’s and who becomes an art writer, is sympathetic. Some are more and some less sympathetic, and all are real, at least those in the constant trade winds of the art world. They either lust after art, or they are in the business of servicing those who have that lust. You will have noticed that the title is a double entendre, some lusting after art, some after Lacey, many after both. And maybe that’s almost the same thing.
What’s it like to be lusted after all your life, to be an object of beauty? That’s Lacey. She knows she is lusted after by most men she meets – that’s us, men! – so she uses it, and has contempt for those who continue to be used by it. Boy, does she use it. When she rides her bike with a halter top and shorts, she listens behind her for the metal clank of bikes crashing as, she imagines, boys and men are looking at her. I guess this is what many beautiful and sexy women deal with – it’s probably hard to do, to figure out who loves you and who is simply lusting for you. Most people probably feel, as with great wealth, I know there are problems, but I wouldn’t mind that challenge. At the end she has a long affair with an FBI agent, the only one she knows below her station, who she always calls “Agent,” and who she loves because he never tells her he loves her.
It’s interesting that Steve has this agent look at a painting he likes – his line is not art appreciation but following art theft, so if he likes something it’s from a very unprofessional view – and he tells Lacey it might be symbolic, explains what symbolic is (thank you, says Lacey), and then says the sea is reality, the sky is the dream, and art is trying to connect one to the other. Sounds like Steve to me.
Steve writes really good sentences. He writes with structure. We hear it referred to that Lacey came into money, and we think, she did? Did I miss exactly how that happened? But it pops up later. The story doesn’t bog down for a minute, and I like his short chapters. I didn’t want the book to end, but still, when I would look ahead and see that it was only a couple of pages, especially since I’m having some trouble with my eyes, it would be a relief. Steve might have started as a showman, but he is a writer, in every good sense of the word. He is a very good writer, and I’m so glad he is.
All of which reminded me of my brush with the art world. It was 1970 and I was in graduate school at Berkeley, my first wife Mary Jane was an undergrad at Mills College, and we lived at the corner of Arch and Hilgard, just a few blocks walk for me to school. She brought home a fellow student one day who lived just a block up the hill from us, a young lady who dressed in a peasant-type dress, I guess it was, and whose chest was very alluring. I was 29 years old and had as much testosterone as most guys that age, probably at the higher end of normal. Truthfully, I just couldn’t get over her chest just below the scoop neckline as we stood there. She was recently married to a guy who I met probably a few days later, it’s hard to remember the details, but I do remember it was hard to think of anything beyond this young woman’s chest, very hard. Anyway, I guess she and her young husband wanted to be friends. He was a nice enough guy on the small side. He was called Dicken, which in German meant little Dick, because he was junior to his father, whose name was Richard.
So, as part of getting to know each other, they said that Dicken’s father was an artist and did I want to meet him and see his studio? I pictured walking up to his house nearby, looking at the studio, who knows what boring stuff I would be faced with. So I demurred, we never became friends with this young couple, life went on, I never met the father. Face it, I was distracted.
And so it was that I never met Richard Diebencorn.
I am such an asshole.
Budd Shenkin
Friday, December 31, 2010
The Lame Duck That Lost It's Limp
It was heartening and amazing to see the Lame Duck congress pass a comprehensive tax program for the next year (however compromised by economically unnecessary but politically necessary giveaways), repeal Don’t Ask Don’t Tell, and pass the New Start treaty. After the goddamnest biggest case of legislative constipation anyone can remember. Everyone is asking, why should this be? Lame ducks are usually the weakest legislative animal in the barnyard.
I don’t know either, since I’m not close to the situation, but I do have some thoughts.
Most important has to be the Obama shellacking. Since the Republicans had gotten scorched two elections in a row previously, this evened the score, and the Republicans could now let things go through without seeming weak. They had just won, they had their honor back, so they could compromise from a position of seeming equality. Politically, their Just Say No strategy had won them the election, so there was little to gain by continuing. By the next election no one will remember the Lame Duck much, and a new electoral strategy will be in place.
And besides, both DADT repeal and New Start were not only popular with the public, but the military were strongly behind both, every past Republican Secretary of State and Dick Lugar were strongly behind New Start, so get it out of the way! Get your own new start.
Kyl and the Turtle (McConnell) had got themselves caught out there on the wing, playing the old game, so for them it was best just to vote as if they still believed what they had said (which they couldn’t have, really), and again, get it out of the way.
I wonder, however, if there isn’t something else happening, and some Republican sensibleness now coming down the pike. There might be a generational split developing in the Senate, as revealed by the current maneuvering to redo the rules in the next Senate – make the filibuster a talking filibuster, reform the initial motion to proceed to discuss legislation, and the placement of secret holds. The younger group (see Tom Udall) wants reform – they want action in the Senate. The leadership on both sides would lose some of their power with these reforms, and so are reluctant to proceed. But the Senate as a body is held in derision by the country as a whole at this point, so even the leadership must be sensitive to that, and maybe there will be some reform.
What about the upcoming term – more like the last term, or more like the Lame Duck? I’m an outsider, so I don’t know, but I suspect that Obama has spent two years learning hard lessons, and he will come back more aggressive, more teaching the country and less making a few lofty speeches that open him to charges of elitism and arrogance. I also think that Just Say No will not be much of a strategy from here on in. So, my prediction would be that there will be action. The President proposes and the Congress disposes. Success will depend on what is proposed. We’ll just have to see.
Budd Shenkin
I don’t know either, since I’m not close to the situation, but I do have some thoughts.
Most important has to be the Obama shellacking. Since the Republicans had gotten scorched two elections in a row previously, this evened the score, and the Republicans could now let things go through without seeming weak. They had just won, they had their honor back, so they could compromise from a position of seeming equality. Politically, their Just Say No strategy had won them the election, so there was little to gain by continuing. By the next election no one will remember the Lame Duck much, and a new electoral strategy will be in place.
And besides, both DADT repeal and New Start were not only popular with the public, but the military were strongly behind both, every past Republican Secretary of State and Dick Lugar were strongly behind New Start, so get it out of the way! Get your own new start.
Kyl and the Turtle (McConnell) had got themselves caught out there on the wing, playing the old game, so for them it was best just to vote as if they still believed what they had said (which they couldn’t have, really), and again, get it out of the way.
I wonder, however, if there isn’t something else happening, and some Republican sensibleness now coming down the pike. There might be a generational split developing in the Senate, as revealed by the current maneuvering to redo the rules in the next Senate – make the filibuster a talking filibuster, reform the initial motion to proceed to discuss legislation, and the placement of secret holds. The younger group (see Tom Udall) wants reform – they want action in the Senate. The leadership on both sides would lose some of their power with these reforms, and so are reluctant to proceed. But the Senate as a body is held in derision by the country as a whole at this point, so even the leadership must be sensitive to that, and maybe there will be some reform.
What about the upcoming term – more like the last term, or more like the Lame Duck? I’m an outsider, so I don’t know, but I suspect that Obama has spent two years learning hard lessons, and he will come back more aggressive, more teaching the country and less making a few lofty speeches that open him to charges of elitism and arrogance. I also think that Just Say No will not be much of a strategy from here on in. So, my prediction would be that there will be action. The President proposes and the Congress disposes. Success will depend on what is proposed. We’ll just have to see.
Budd Shenkin
Friday, December 24, 2010
Tales of a German Urologist
Urology is not where one usually turns for wisdom – humor of a certain sort sometimes, but not wisdom. Still, within humor there is often wisdom, and in a package that is easy to accept.
Enter my colleague Bernd Schmidt of Pleasanton. A tall man with a craggy face hidden by a rather sparse beard and ever-ready grin, he has a strong German accent that demands close attention to understand him. I really don’t know him that well, but I thought he introduced himself as “Ban,” so that’s what I call him at the doctors’ lunch table at ValleyCare Hospital, be it nickname, the pronunciation of Bernd, his accent, or my poor hearing.
Each specialty in medicine has its own stereotype, and as with most stereotypes, there is a core of accuracy. I once introduced myself at a party of lawyers in the City as a pediatrician, and was told that “you guys are all alike.” Yup, I could have replied, and so are lawyers, as typified by that remark by you, asshole.
But I digress. Internists are removed, cerebral or pseudo-cerebral, not the warmest buns on the table. Surgeons are cowboys who can’t wait to cut but can’t think well or broadly. Orthopedists are strong as an ox, and twice as smart. Urologists – well, urologists. They have a very down to earth attitude, shall we say. My med school classmates told me to prepare for a unique experience in my one-week Mass General urology rotation. They were right. My residents gloried in making rounds while smoking cigars, inquiring of their patients amid their smoke, “How you doin’?” Actually, It was refreshing not having to deal with the poseurs the MGH was rife with.
One of my classmates was interviewing for a surgery residency in at MGH with George Nardi, who had some post in the department. He waited for a while for Nardi in his hospital office, a converted exam room. Then Nardi burst in, hustled over to the sink, pulled out his penis and pissed right in the sink, with a gasp of relief saying, “Sometimes you just gotta go.” Nardi should have been a urologist.
My colleague Ban has a typical urologist get-rich scheme, inspired by the plastic surgeons. He wants to use Botox injections to take the wrinkles out of the scrotum. “Wouldn’t they be beautiful?” OK, Ban, good. You’re a urologist, all right. Wish you smoked a cigar. Maybe your scheme will work in San Francisco, who knows?
Ban had two stories yesterday at lunch. He related that in Germany you never, ever, marred the bed sheets of a patient. The German passion for order and cleanliness prevailed. So he was shocked when he came to America in training and saw that the urologists on rounds routinely used the bed sheets to write on as they made rounds. My MGH urologists were too busy with their cigars to write on sheets, but it did seem right in character.
But Ban said it didn’t always work out too well. A few weeks into it he was standing at the foot of the bed as the urology staff was gather on each side of the bed, discussing the case over the patients supine body, his head sticking out from under the sheets as he listened. The urologists drew pictures on the sheets, depicting the anatomy underneath. But what they didn’t notice was the patient. As they drew and discussed, “Then we’ll cut here, and then here, then pull this together,” and so on, the patients face became paler and paler, visible only to Ban at the bottom of the bed, as the others were in heated discussion. Finally, as they agreed, “Right, this is just where we’ll cut,” the patient sat up and vomited everything he had all over the bed sheets, the pictures, the pens, their hands, and their cuffs. Urologists.
But on a more serious note, Ban has another side to him, a really lovely and understanding, which is to say, perhaps a non-urological side. I told Ban that I had always been fascinated by Germany, but that as a Jew I had of course ambivalence, to say the least. Still, my father had been one of the first to buy a VW in the United States, on the grounds that it was pretty cheap. So my family heritage enabled me to be somewhat dispassionate. Ban is from the Hamburg area, and I said I had heard that the real rapid anti-Semitism was in the south, and especially in Austria.
Ban agreed. He reflected that as a German medical student he could change schools each semester within the German community, just so long as he passed all his requirements. So one semester he decamped to Vienna, where he rented a room in a house where the only TV was in the landlady’s living room. So he was watching TV with her one evening and there was a documentary of some sort about the holocaust, and Austria’s experiences. His landlady denied that there was much anti-Semitism in Austria. She said, “All that never happened here in Austria. It’s a lie. This movie must have been made by some Jew.”
Ban has remembered this story a long time. Reminds me of how one of my very favorite authors, Alan Furst, has never written about Austria and Vienna. “Just never wanted to do it,” he said at one of his readings I attended. Probably one of the cities I won’t visit, either.
It’s good to eat In the doctors’ dining room. You meet the most interesting people. Even urologists.
Budd Shenkin
Enter my colleague Bernd Schmidt of Pleasanton. A tall man with a craggy face hidden by a rather sparse beard and ever-ready grin, he has a strong German accent that demands close attention to understand him. I really don’t know him that well, but I thought he introduced himself as “Ban,” so that’s what I call him at the doctors’ lunch table at ValleyCare Hospital, be it nickname, the pronunciation of Bernd, his accent, or my poor hearing.
Each specialty in medicine has its own stereotype, and as with most stereotypes, there is a core of accuracy. I once introduced myself at a party of lawyers in the City as a pediatrician, and was told that “you guys are all alike.” Yup, I could have replied, and so are lawyers, as typified by that remark by you, asshole.
But I digress. Internists are removed, cerebral or pseudo-cerebral, not the warmest buns on the table. Surgeons are cowboys who can’t wait to cut but can’t think well or broadly. Orthopedists are strong as an ox, and twice as smart. Urologists – well, urologists. They have a very down to earth attitude, shall we say. My med school classmates told me to prepare for a unique experience in my one-week Mass General urology rotation. They were right. My residents gloried in making rounds while smoking cigars, inquiring of their patients amid their smoke, “How you doin’?” Actually, It was refreshing not having to deal with the poseurs the MGH was rife with.
One of my classmates was interviewing for a surgery residency in at MGH with George Nardi, who had some post in the department. He waited for a while for Nardi in his hospital office, a converted exam room. Then Nardi burst in, hustled over to the sink, pulled out his penis and pissed right in the sink, with a gasp of relief saying, “Sometimes you just gotta go.” Nardi should have been a urologist.
My colleague Ban has a typical urologist get-rich scheme, inspired by the plastic surgeons. He wants to use Botox injections to take the wrinkles out of the scrotum. “Wouldn’t they be beautiful?” OK, Ban, good. You’re a urologist, all right. Wish you smoked a cigar. Maybe your scheme will work in San Francisco, who knows?
Ban had two stories yesterday at lunch. He related that in Germany you never, ever, marred the bed sheets of a patient. The German passion for order and cleanliness prevailed. So he was shocked when he came to America in training and saw that the urologists on rounds routinely used the bed sheets to write on as they made rounds. My MGH urologists were too busy with their cigars to write on sheets, but it did seem right in character.
But Ban said it didn’t always work out too well. A few weeks into it he was standing at the foot of the bed as the urology staff was gather on each side of the bed, discussing the case over the patients supine body, his head sticking out from under the sheets as he listened. The urologists drew pictures on the sheets, depicting the anatomy underneath. But what they didn’t notice was the patient. As they drew and discussed, “Then we’ll cut here, and then here, then pull this together,” and so on, the patients face became paler and paler, visible only to Ban at the bottom of the bed, as the others were in heated discussion. Finally, as they agreed, “Right, this is just where we’ll cut,” the patient sat up and vomited everything he had all over the bed sheets, the pictures, the pens, their hands, and their cuffs. Urologists.
But on a more serious note, Ban has another side to him, a really lovely and understanding, which is to say, perhaps a non-urological side. I told Ban that I had always been fascinated by Germany, but that as a Jew I had of course ambivalence, to say the least. Still, my father had been one of the first to buy a VW in the United States, on the grounds that it was pretty cheap. So my family heritage enabled me to be somewhat dispassionate. Ban is from the Hamburg area, and I said I had heard that the real rapid anti-Semitism was in the south, and especially in Austria.
Ban agreed. He reflected that as a German medical student he could change schools each semester within the German community, just so long as he passed all his requirements. So one semester he decamped to Vienna, where he rented a room in a house where the only TV was in the landlady’s living room. So he was watching TV with her one evening and there was a documentary of some sort about the holocaust, and Austria’s experiences. His landlady denied that there was much anti-Semitism in Austria. She said, “All that never happened here in Austria. It’s a lie. This movie must have been made by some Jew.”
Ban has remembered this story a long time. Reminds me of how one of my very favorite authors, Alan Furst, has never written about Austria and Vienna. “Just never wanted to do it,” he said at one of his readings I attended. Probably one of the cities I won’t visit, either.
It’s good to eat In the doctors’ dining room. You meet the most interesting people. Even urologists.
Budd Shenkin
Sunday, December 12, 2010
Tales of Worker-Management Cronyism
The auto industry, civil service, and our old friend health care – three separate very troubled American industries. But if you look at them critically, it seems to me they have a certain sameness, which then makes me think they might reflect a more general American problem.
I have recounted the tale of the auto industry before (see Paul Ingrassia’s book, Crash Course.) The auto industry was a major success of modern industrialization. Three large companies emerged with one large union. The UAW wrested very high wages and benefits from employers, extensive and strict work rules, company pay for union organizing jobs, and a job bank where workers were paid for years not to work. The success that liberals now celebrate was that, thanks to union power, line workers entered the middle class. I, too, like to see people do well, but in this case the collateral damage was really unacceptable.
As the UAW thrived, management didn’t do its job. They not only caved to the UAW, they also pursued their own slothful and self-indulgent agenda. The managers were not unhappy to see workers’ pay improve, because they simply applied a multiple of that pay to compute their own. They exerted no quality and efficiency discipline, they continued to populate their own managerial ranks with the mediocre products of local feeder educational institutions, and they passed costs onto the public. When Japanese competition appeared the American auto industry had so little muscle and so much fat that they simply went lifeless, dead by their own hand and evil constitution.
We are also now facing a crisis in civil service. I don’t know how it arose, but the civil service deal has been a tradeoff of lower wages for better benefits and security. The civil service was supposed to be quiescent and not union organized. The deal started to unravel when unionization was allowed. We are now faced with civil service workers who retain their security, but who now have generous pay and benefits while they work, and pension plans that will soon bankrupt the country. Civil servants can retire after 30 years of service, sometimes even earlier, which lets many retire before they do in France or Greece, at nearly full salary. Not content with that, many have plans whereby they get a percentage, sometimes 100%, of their highest yearly salary. They can accrue vacation time and other bonuses until one year when they get a large spike of salary, and that’s the base they figure from. These retirement benefits are generally unfunded. That is, they need to be paid for by others than those who granted the benefits, because they were future benefits.
Who was on the other side of the bargaining when these deals were struck? Civil servant managers and politicians. The problem was that as soon as you have unions, you have political campaign contributions – the best example in the world being the California prison guards union. In addition, city and county managers responsible for recommending solutions to the political powers are similar to the auto managers. The managers’ financial fate is aligned with that of the other workers, rather than opposed. So, we have had managers who will benefit by caving into union demands, and politicians who can curry present favor in exchange for someone in the future having to deal with it.
As a result, we are in the soup. Unfunded obligations simply hang over us. As with auto management and workers, politicians and civil service workers act more like cronies than adversaries, and the public takes it in the neck.
Finally, the health care industry also has common elements. Hospitals drive health care costs. Hospitals can compete with each other for business, but if they cut costs and become more efficient, what have the managers really gained? The way health care is set up, a lower cost provider doesn’t really gain anything. Because patients and referring physicians do not pay much of the cost directly themselves, it is better for a hospital to be fat with patient amenities, and fat with rich physician “directorships” of various services and departments, and fat by giving into the relentless demands of the nursing unions and SEIU. A larger hospital budget translates into larger manager salaries and perks. Let the pubic pay, now just about to the breaking point.
These three industries seem to have the same dynamic – lack of competition to discipline the managers, and a resultant cronyism between management and workers to the detriment of the public. It would be nice if managerial professionalism led the managers to stand up for the public interest, but people being people, that doesn’t happen. Would that there would be the equivalent of the Hippocratic Oath for professional managers and politicians, but that doesn’t even work consistently for physicians.
In our mixed economy, when a market isn’t working, government is supposed to intervene, and either make rules to create a market that works, or to enforce an administrative solution. You can see how that didn’t work in the auto industry, is not yet working in health care, and government is itself the problem in civil service. My own sense is that government could be made to work in all three instances if we had the will and wisdom. A stronger government more impervious to business influence could adjust cases one and three, and governmentally appointed independent commissions could have warded off the civil service disaster.
Government needs to be better, smarter, more professional, more independent -- just better. We need leaders! We don’t need Plato’s guardians, but do need big guys, smart guys, aggressive guys on our side. Guys like my hero, Elizabeth Warren. We don’t need bigger government, we need better government.
Which is why I support the Goldman School of Public Policy at the University of California, Berkeley, my alma mater. Maybe fine professional schools harbor the long term solution. We should think up a professional oath for them.
So what do we do in the meanwhile? Yesterday my wife and I went shopping in downtown San Francisco. It was a sunny day in the low 60’s with happy crowds. We walked in the sun, we ate lunch, the fries were really good, we laughed. Life goes on.
I was buying baubles at Gumps, where we had somehow wound up, and Ann took little 10 month old Lola outside to wait for me. She is a happy baby, but this time she sat down on the sidewalk and cried. As Ann picked her up, a nice man on the way into the store said wryly, “I wish I could do that, sit down on the sidewalk and cry!”
Sometimes, so do I.
Budd Shenkin
I have recounted the tale of the auto industry before (see Paul Ingrassia’s book, Crash Course.) The auto industry was a major success of modern industrialization. Three large companies emerged with one large union. The UAW wrested very high wages and benefits from employers, extensive and strict work rules, company pay for union organizing jobs, and a job bank where workers were paid for years not to work. The success that liberals now celebrate was that, thanks to union power, line workers entered the middle class. I, too, like to see people do well, but in this case the collateral damage was really unacceptable.
As the UAW thrived, management didn’t do its job. They not only caved to the UAW, they also pursued their own slothful and self-indulgent agenda. The managers were not unhappy to see workers’ pay improve, because they simply applied a multiple of that pay to compute their own. They exerted no quality and efficiency discipline, they continued to populate their own managerial ranks with the mediocre products of local feeder educational institutions, and they passed costs onto the public. When Japanese competition appeared the American auto industry had so little muscle and so much fat that they simply went lifeless, dead by their own hand and evil constitution.
We are also now facing a crisis in civil service. I don’t know how it arose, but the civil service deal has been a tradeoff of lower wages for better benefits and security. The civil service was supposed to be quiescent and not union organized. The deal started to unravel when unionization was allowed. We are now faced with civil service workers who retain their security, but who now have generous pay and benefits while they work, and pension plans that will soon bankrupt the country. Civil servants can retire after 30 years of service, sometimes even earlier, which lets many retire before they do in France or Greece, at nearly full salary. Not content with that, many have plans whereby they get a percentage, sometimes 100%, of their highest yearly salary. They can accrue vacation time and other bonuses until one year when they get a large spike of salary, and that’s the base they figure from. These retirement benefits are generally unfunded. That is, they need to be paid for by others than those who granted the benefits, because they were future benefits.
Who was on the other side of the bargaining when these deals were struck? Civil servant managers and politicians. The problem was that as soon as you have unions, you have political campaign contributions – the best example in the world being the California prison guards union. In addition, city and county managers responsible for recommending solutions to the political powers are similar to the auto managers. The managers’ financial fate is aligned with that of the other workers, rather than opposed. So, we have had managers who will benefit by caving into union demands, and politicians who can curry present favor in exchange for someone in the future having to deal with it.
As a result, we are in the soup. Unfunded obligations simply hang over us. As with auto management and workers, politicians and civil service workers act more like cronies than adversaries, and the public takes it in the neck.
Finally, the health care industry also has common elements. Hospitals drive health care costs. Hospitals can compete with each other for business, but if they cut costs and become more efficient, what have the managers really gained? The way health care is set up, a lower cost provider doesn’t really gain anything. Because patients and referring physicians do not pay much of the cost directly themselves, it is better for a hospital to be fat with patient amenities, and fat with rich physician “directorships” of various services and departments, and fat by giving into the relentless demands of the nursing unions and SEIU. A larger hospital budget translates into larger manager salaries and perks. Let the pubic pay, now just about to the breaking point.
These three industries seem to have the same dynamic – lack of competition to discipline the managers, and a resultant cronyism between management and workers to the detriment of the public. It would be nice if managerial professionalism led the managers to stand up for the public interest, but people being people, that doesn’t happen. Would that there would be the equivalent of the Hippocratic Oath for professional managers and politicians, but that doesn’t even work consistently for physicians.
In our mixed economy, when a market isn’t working, government is supposed to intervene, and either make rules to create a market that works, or to enforce an administrative solution. You can see how that didn’t work in the auto industry, is not yet working in health care, and government is itself the problem in civil service. My own sense is that government could be made to work in all three instances if we had the will and wisdom. A stronger government more impervious to business influence could adjust cases one and three, and governmentally appointed independent commissions could have warded off the civil service disaster.
Government needs to be better, smarter, more professional, more independent -- just better. We need leaders! We don’t need Plato’s guardians, but do need big guys, smart guys, aggressive guys on our side. Guys like my hero, Elizabeth Warren. We don’t need bigger government, we need better government.
Which is why I support the Goldman School of Public Policy at the University of California, Berkeley, my alma mater. Maybe fine professional schools harbor the long term solution. We should think up a professional oath for them.
So what do we do in the meanwhile? Yesterday my wife and I went shopping in downtown San Francisco. It was a sunny day in the low 60’s with happy crowds. We walked in the sun, we ate lunch, the fries were really good, we laughed. Life goes on.
I was buying baubles at Gumps, where we had somehow wound up, and Ann took little 10 month old Lola outside to wait for me. She is a happy baby, but this time she sat down on the sidewalk and cried. As Ann picked her up, a nice man on the way into the store said wryly, “I wish I could do that, sit down on the sidewalk and cry!”
Sometimes, so do I.
Budd Shenkin
Wednesday, December 8, 2010
Health Care Costs
In response to my last post, from a colleague:
Hi Budd,
We all have our stories. I had radiation therapy for cancer. 12 weeks, 15 minutes a day. The charge was $3500. Per day. That’s 60 days treatment at $3500. $210,000. BCBS paid at 100%. I am lucky to get 80% on a $85 office visit.
What is going on here, with these costs? As I've said before, let's forget utilization - what about prices? There is just no curbing them at present, and to my mind no prospect of such. Here in the East Bay, the rising cost of health insurance, which is a consequence of these prices, is simply driving more and more people to Kaiser, which can control its prices. This exodus from private insurance reduces the pool of private patients at Sutter and elsewhere, who respond by raising prices even higher. This is what is called a death spiral.
Nothing goes on forever, so there will be an end to it, but it's hard to see right now what that end will be. I wish I could be brilliant and see it, but I'll leave that for the often-wrong economists. The idea of ACO's, like HMO's before them, is for a group of providers to be able to look at a group of patients and plan rationally for their efficient care, saving money and distributing it to themselves and kicking some back to the government, but it's a speculative program and will take some time to take effect. In the meantime life goes on, trends continue, and anti-trust is silent.
Budd Shenkin
Hi Budd,
We all have our stories. I had radiation therapy for cancer. 12 weeks, 15 minutes a day. The charge was $3500. Per day. That’s 60 days treatment at $3500. $210,000. BCBS paid at 100%. I am lucky to get 80% on a $85 office visit.
What is going on here, with these costs? As I've said before, let's forget utilization - what about prices? There is just no curbing them at present, and to my mind no prospect of such. Here in the East Bay, the rising cost of health insurance, which is a consequence of these prices, is simply driving more and more people to Kaiser, which can control its prices. This exodus from private insurance reduces the pool of private patients at Sutter and elsewhere, who respond by raising prices even higher. This is what is called a death spiral.
Nothing goes on forever, so there will be an end to it, but it's hard to see right now what that end will be. I wish I could be brilliant and see it, but I'll leave that for the often-wrong economists. The idea of ACO's, like HMO's before them, is for a group of providers to be able to look at a group of patients and plan rationally for their efficient care, saving money and distributing it to themselves and kicking some back to the government, but it's a speculative program and will take some time to take effect. In the meantime life goes on, trends continue, and anti-trust is silent.
Budd Shenkin
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