House Calls, STAT!

Just up at THCB:

Should Doctors and Nurses Be Patient Activists?
By DANIELLE OFRI, MD

…Like most doctors and nurses, I try to keep the outside world firmly outside the exam room. I don’t talk about politics, religion, money, or sports. I don’t even gripe about the mayor. Most medical professonals avoid political activism for the same reason. But could that reticence be harmful to our patients?

I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

What would I do, I asked myself, if I started to notice a dangerous side effect of a medication that my patients were taking. The answer, of course, is easy. And it wouldn’t even be a question; it would be an obligation. If I see a threat to my patients’ health, it’s in my job description to speak up.

The ACHA and BCRA suddenly seemed like the same thing—a threat to my patients’ health. Yes, I value political neutrality, but this no longer seemed like politics to me. It was a medical threat…

If I suspect that one of my patients is suffering abuse at home, I am obligated—in fact, legally mandated—to speak up.  If I suspect that my patients’ health will be harmed by legislation, I believe we are equally obligated to speak up…

I’ve thought long and hard about whether this violates my commitment to political neutrality with my patients and I’ve concluded that it does not. I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor. When I leave the hospital, I start calling Senators about BCRA because that is also my job as their doctor.

Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients. It’s a medical emergency, and medical professionals need to behave as such.

I have cited the eloquent and empathic Dr. Ofri many times on this blog. See, e.g., here, here, and here.

Dr. Ofri's new book:

"Despite modern medicine’s infatuation with high-tech gadgetry, the single most powerful diagnostic tool is the doctor-patient conversation, which can uncover the lion’s share of illnesses. However, what patients say and what doctors hear are often two vastly different things.

Patients, anxious to convey their symptoms, feel an urgency to “make their case” to their doctors. Doctors, under pressure to be efficient, multitask while patients speak and often miss the key elements. Add in stereotypes, unconscious bias, conflicting agendas, and fear of lawsuits and the risk of misdiagnosis and medical errors multiplies dangerously..."

 Not read it yet. Into the never-ending queue it goes.

In her THCB post, she alludes to the #HouseCallsCampaign.

Every day, we medical professionals advocate on behalf of our patients.

Right now, millions of our patients stand to lose their health insurance if the Senate passes their healthcare bill. This would be disastrous for their health.

When a new drug comes on the market, we ask ourselves whether it would harm our patients before prescribing it. We need to think the same way about healthcare legislation.
If you think that the proposed legislation could harm your patients, join doctors, nurses and medical caregivers across the country who are calling the Senate. (We’ve named this the HouseCalls Campaign even though it’s the Senate that needs our medical opinion right now!)

As we all know, advocating for patients is as much a part of medical care as the medical care itself. It  takes only a few minutes to make a call.

#HouseCallsCampaign

"Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients."

I don't think you'd have to look far these days to find a Republican who might allude to it as "culling the herd" if he thought he was speaking off the record. We seem to be rather firmly in the hard-hearted political nadir grip of the "Persecutor" phase of the "Rescuer - Victim - Persecutor Triangle."

The other day I saw an estimate of the U.S. medically uninsured rising to a total of 49 million or so in a decade should the GOP BRCA bill pass and become law. I did a quick Excel sheet.

Assume a blended annual compounding health care cost increase of 5% (current 1.9% "core" inflation plus general cost health sector increases above and beyond the inflation rate).

The latest per capita estimate per the NHE is ~$10,500. By 2021 the annual cost of just the uninsureds (assuming a total of 38M by then) approaches that of the entire U.S. Defense Budget. By 2026, assuming 49M uninsureds, the yearly price tag rises to about $800 billion --- with a "B."

And, yes, I know that this scenario further assumes that the per capita health care burden of the uninsureds is roughly reflective of the aggregate average (and, it's not much of a stretch to make the case that this overwhelmingly poorer demographic is and will be more costly). That's why you spreadsheet this stuff, to play with the various parameter estimates.

These costs (whatever their precise out-years magnitude) will get paid for one way or another.

Or, maybe not. We could just "cull the herd." Hey, I know! -- Rand Paul could introduce a bill to Repeal the EMTALA. And, "Rationing by 'Price'." (As in "priced out.")

Once again, I tout Elisabeth Ronsethal's excellent book "An American Sickness." See also my review of "ObamaCare is a Great Mess."

Make some House Calls.

INTERESTING TALK BY NORTIN HADLER, MD

 

UPDATE: TRUMP VOTER MARGALIT IS NOT IMPRESSED WITH DR. OFRI'S THCB PLEA

"Yes, I fully appreciate the sentiments here and I believe doctors, like all other individuals, should be politically active. The health care legislation issue may feel more like an Ebola, but is it really? And isn’t this a bit late to the political “saving lives” game?

Without further ceremony, and please forgive me, but where were all concerned physicians during the last few decades when American workers had to watch their wages deteriorate to the point of having to rely on Medicaid and all sorts of other charity just to survive? Where were all the doctors when successive administrations traded away the U.S. middle class at the behest of global corporations and deranged activist billionaires?

Where were the doctors when our education system turned into third world crap, our inner cities collapsed and entire generations of boys and men of a certain color got carted away to prison? Where were the doctors when wars were/are fought for imaginary excuses and when the goddamn “resistance” is beating the drums of war with the largest nuclear power out there?

Where were the doctors when tech companies pushed their sick and addictive products on millions of children, who are wasting their lives powering the tech exploitation machine? And recommending optimal “screen times” doesn’t count. Speaking of addiction, where were the doctors when America plunged into an opioid addiction and mortuaries in small towns began to overflow with victims?

So my question is why now? Why is health insurance different than the other horrific events where your patients were/are literally being killed, not just estimated to maybe be killed in 2037?

Perhaps if I would have seen doctors marching against poverty, worker exploitation, slave-labor importation, environmental destruction, and such, this newfound political activism would not look so peculiar. And maybe, just maybe, if doctors started marching against those patient-killing evils decades ago, we wouldn’t have to march today.

Other than that, excellent article, as usual."

Yikes. From Donald Trump's Bolshevik in Chief. I have no way to know whether she's a seasoned front-line veteran of the Occupy Social Justice barricades or just another affluent First Chairborne Division Keyboard Commando.

MORE DANIELLE OFRI

Doctors and Nurses Need to Treat BCRA as a Medical Emergency
This isn’t about politics, it’s about health.
By Danielle Ofri 

Illness is not something most healthy people think about regularly. And they shouldn’t. Although as a physician I want to help my patients make smart choices to preserve their healthy state, I also don’t want to deny them the blissful innocence that comes with taking good health for granted.

However, just as the disability community coined the term “temporarily able” to refer to those without disabilities, the reality is that those of us who are healthy are only “temporarily healthy.”

A random encounter with an unprotected partner or a nasty stomach bug or the Second Avenue bus could bring anyone at any age into contact with the health care system. Just getting older and acquiring hypertension or arthritis can do it. And then suddenly you learn. You learn what your insurance does or does not cover. Or you learn what it means to get sick without insurance. You learn that you are not invincible.

For Americans who are still temporarily healthy, the politics of health care can feel distant. The details of the House and Senate’s health care bills can feel arcane and overly partisan...
 
Most senators have only a passing knowledge of what actually transpires when people make medical decisions. It is the people in the clinical trenches—nurses, doctors, physician assistants, med students—who know. These are the people who understand what happens when patients lose access to medical care. These are the people who will care for those 20,000 ill-fated patients—not in primary care clinics but in emergency rooms, ICUs, and morgues...

BTW, Michael Millenson posted the best comment under the THCB post that gave rise to this one of mine:

"Doctors always believe that the alarms they raise about any action by federal or state government, insurers, employers, health plans, hospitals, other medical specialties, other doctors in the same specialty who aren’t as smart/competent/ethical as they are and anything else related to health care are actions undertaken altruistically out of concern for patients.

As a result, some doctors warn that a single payer system, a la Canada, will kill patients, while other doctors warn just as sincerely that failing to adopt such as system will kill patients. While other doctors, of course, have every other opinion in between.

Because so many doctors, like Danielle Ofri, are eloquent writers, I believe all of them all at once all of the time."

UPDATE: MORE NEWS...

With ‘shame on you’ chants and harsh tweets, nurses union pushes single-payer bill
By PAULINE BARTOLONE — CALIFORNIA HEALTHLINE JULY 11, 2017
To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, New Jersey-ish.

Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.

To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.

Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.

Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly…

Things are getting increasingly heated.

UPCOMING: SAVE THE DATE

In addition to the 11th Annual Health 2.0 Conference (link at the top right of this blog), this should be on your calendar.

Registration link here

In the last 10+ years, Precision Medicine has seen a multitude of advances in the areas of diagnostics, computing, and consumer tools. The ongoing quest to better understand disease predisposition and prevention through genomic and environmental factors is key to increasing the quality and length of life. The Technology for Precision Health Summit, this coming October, will explore and showcase specific technology that tackles these issues and more.

CODA

Speaking of human health writ large, I give you a frightening, depressing article:

The Uninhabitable Earth
Famine, economic collapse, a sun that cooks us: What climate change could wreak — sooner than you think.
By David Wallace-Wells 

I. ‘Doomsday’

Peering beyond scientific reticence.

It is, I promise, worse than you think. If your anxiety about global warming is dominated by fears of sea-level rise, you are barely scratching the surface of what terrors are possible, even within the lifetime of a teenager today. And yet the swelling seas — and the cities they will drown — have so dominated the picture of global warming, and so overwhelmed our capacity for climate panic, that they have occluded our perception of other threats, many much closer at hand. Rising oceans are bad, in fact very bad; but fleeing the coastline will not be enough.

Indeed, absent a significant adjustment to how billions of humans conduct their lives, parts of the Earth will likely become close to uninhabitable, and other parts horrifically inhospitable, as soon as the end of this century...
___

IV. Climate Plagues

What happens when the bubonic ice melts?

Rock, in the right spot, is a record of planetary history, eras as long as millions of years flattened by the forces of geological time into strata with amplitudes of just inches, or just an inch, or even less. Ice works that way, too, as a climate ledger, but it is also frozen history, some of which can be reanimated when unfrozen. There are now, trapped in Arctic ice, diseases that have not circulated in the air for millions of years — in some cases, since before humans were around to encounter them. Which means our immune systems would have no idea how to fight back when those prehistoric plagues emerge from the ice.

The Arctic also stores terrifying bugs from more recent times. In Alaska, already, researchers have discovered remnants of the 1918 flu that infected as many as 500 million and killed as many as 100 million — about 5 percent of the world’s population and almost six times as many as had died in the world war for which the pandemic served as a kind of gruesome capstone. As the BBC reported in May, scientists suspect smallpox and the bubonic plague are trapped in Siberian ice, too — an abridged history of devastating human sickness, left out like egg salad in the Arctic sun.

Experts caution that many of these organisms won’t actually survive the thaw and point to the fastidious lab conditions under which they have already reanimated several of them — the 32,000-year-old “extremophile” bacteria revived in 2005, an 8 million-year-old bug brought back to life in 2007, the 3.5 million–year–old one a Russian scientist self-injected just out of curiosity — to suggest that those are necessary conditions for the return of such ancient plagues. But already last year, a boy was killed and 20 others infected by anthrax released when retreating permafrost exposed the frozen carcass of a reindeer killed by the bacteria at least 75 years earlier; 2,000 present-day reindeer were infected, too, carrying and spreading the disease beyond the tundra.

What concerns epidemiologists more than ancient diseases are existing scourges relocated, rewired, or even re-evolved by warming. The first effect is geographical. Before the early-modern period, when adventuring sailboats accelerated the mixing of peoples and their bugs, human provinciality was a guard against pandemic. Today, even with globalization and the enormous intermingling of human populations, our ecosystems are mostly stable, and this functions as another limit, but global warming will scramble those ecosystems and help disease trespass those limits as surely as Cortés did. You don’t worry much about dengue or malaria if you are living in Maine or France. But as the tropics creep northward and mosquitoes migrate with them, you will. You didn’t much worry about Zika a couple of years ago, either.

As it happens, Zika may also be a good model of the second worrying effect — disease mutation. One reason you hadn’t heard about Zika until recently is that it had been trapped in Uganda; another is that it did not, until recently, appear to cause birth defects. Scientists still don’t entirely understand what happened, or what they missed. But there are things we do know for sure about how climate affects some diseases: Malaria, for instance, thrives in hotter regions not just because the mosquitoes that carry it do, too, but because for every degree increase in temperature, the parasite reproduces ten times faster. Which is one reason that the World Bank estimates that by 2050, 5.2 billion people will be reckoning with it...

Read all of it.
____________

More to come...

Reflecting on the Electronic Medical Record

Happy MayDay, btw.

Ten years ago this month I took my retirement from HealthInsight, the Nevada-Utah Medicare QIO. It'd been my 3rd tenure with them, and the focus of this work was on the federal "Meaningful Use" initiative, via which to accelerate the conversion of outpatient primary care clinics from paper-based medical records to HHS "Certified EMRs" (Electronic Medical Records, also more broadly dubbed "EHRs"—Electronic Health Records).

 

The goal—and assumption—was quantifiably improved health care outcomes resulting from having digitized current and longitudinal patient data always close at "hand" (literally, via keystrokes or mouse clicks).

 

I was certainly a Kool-aid drinking True Believer at the outset, particularly in light of my lengthy former work as a laboratory programmer and QC statistician (pdf) in Oak Ridge, and my abiding interest in all things QI as an ASQ Certified Quality Engineer. Things would turn out to be considerably more complex, however.

 

This morning I opened my New Yorker to find this:

The Curious Side Effects of Medical Transparency
When we peer into our patient portals, we don’t always see ourselves more clearly.
By Danielle Ofri

One afternoon not long ago, I sat entering notes into a patient’s medical record. She was in her forties, and her labs showed anemia. The causes of anemia range from menstruation to cancer, and so pinpointing the correct underlying diagnosis is critical. Physicians are trained to formulate a full roster of possibilities, known as the differential diagnosis, and then to work down the list systematically. We’re taught to cast a wide net—celiac disease, parasitic infections, thalassemia, lead poisoning, liver disease, B12 deficiency, myeloma, sickle-cell disease, G6PD deficiency—because you’ll never make a diagnosis if you haven’t included it in your differential.

But I hesitated before entering my differential into the computer system. Should I include the more serious possibilities, even though they were much less likely? In the past, I wouldn’t have thought twice about it, as the chart served primarily as a tool for the medical team to communicate among ourselves. But a new law, the 21st Century Cures Act, had recently been fully implemented, making medical records open to patients by default, in real time, including doctors’ notes. My in-box was already jammed with panicked messages from people convinced that they had catastrophic illnesses, based on minuscule lab discrepancies and panic-inducing Google searches. How would my patient react to seeing my ruminations about possible colon cancer or duodenal ulcer in the note?…

From my end of the stethoscope, it’s always seemed obvious that patients should own their medical records, and be able to see them. But openness can be challenging in practice. When our hospital initially rolled out its patient portal, a few of my older patients asked that I remove references to erectile dysfunction from their medical records. Their adult children handled the household tech, they explained, and my patients preferred to keep their Viagra prescriptions private. In other cases, multiple family members can access a patient’s chart, messaging me about test results and treatment plans, and it can be complicated to deduce the hierarchy of responsibility. Advocates have raised increasing concerns about the ease with which abusers can gain access to victims’ medical records; health-care settings have traditionally been secure places for people experiencing domestic violence, elder abuse, and human trafficking, but, with medical records becoming more accessible, patients may feel less certain that their words are safe.

At the same time, there are remarkable upsides to the transparent medical record. Patients are able to review their diagnoses, medications, and treatments at their own pace. They are able to share information with family members if they choose. They can spot errors—medications they are no longer taking, medical history that’s missing, allergies that aren’t noted. They can prepare for their next visit, and perhaps feel on more equal footing with their doctor. And they can obtain test results without the interminable wait for the doctor’s call.

Medicine is a highly specialized field, and like philosophy it involves the challenge of bridging the gap between experts and nonexperts. Regulations coming out of the Cures Act prohibit “information blocking,” and in effect require that test results and doctors’ notes be released immediately to patient portals. In practice, this means that patients often see results before their doctors do and are presented with a fire hose of raw data, shorn of context. And yet on many patient portals, because of algorithms that offer only a binary distinction between normal and abnormal, lab values that stray a meaningless half percentage point out of range are labelled as “abnormal” along with results that have grave portent. Doctors’ ubiquitous use of multicomponent lab panels, which bundle together many different tests, virtually guarantees that every patient receives at least one “abnormal,” which, in our hospital’s system, is written in blood-red letters with garish yellow highlighting, plus an exclamation point, just in case the takeaway hasn’t been fully conveyed. Even seemingly straightforward yes-or-no results, such as those from H.I.V. or covid tests, can be easily misinterpreted, since false positives and false negatives occur depending on the course of the disease and the operating characteristics of the test. Meanwhile, results such as CT scans and MRIs often contain paragraphs’ worth of information that looks alarming but isn’t. Try reading the CT report of your lumbar spine and not coming away convinced that you’ll be paralyzed for life.

Patients turn from the portal to Google, then flood doctors’ in-boxes with messages, panicked by the possibility that they have cancer or multiple sclerosis or any of an assortment of inglorious diseases that appear on the Internet grossly out of proportion to their actual prevalence. But some abnormal test results will indeed be real, and some will be seriously concerning. In our current transparent system, tests showing brain atrophy or liver masses are released to the portal in the same manner as cholesterol levels and blood-pressure readings. For some patients, discovering these results on their own can be empowering; for others, it can be catastrophic. In one devastating stretch of twenty-four hours, two of my patients learned of their cancers’ metastatic reappearance by way of the portal. Their in-boxes pinged with new test results; they read them before either their oncologist or I had even seen the scans, let alone called.

Each morning, I log into our medical-record system with a certain amount of dread. Which will I tackle first—the torrent of test results or the deluge of responses it’s inspired? Some patients will have to be talked down from a ledge over a minor lab abnormality. Far worse is the serious result to which I haven’t yet had time to formulate a response: a biopsy result for which I’ve not yet tracked down the appropriate specialist to sketch a road map, or an adrenal mass on a CT scan for which I’ve not yet orchestrated the intricate endocrine evaluation. In the past, I’d do the legwork before I called the patient. Now that buffer is gone, and I am pressured to act immediately: the patient has seen the result, and further delay would be unconscionable. This timbre of rush imperils thoughtful analysis, and I worry incessantly about missteps…

It's a paywalled long-read, and well worth your time.

Long-time Danielle Ofri FanBoy here.

Her most recent book.

CHAPTER ONE
JUMBO JETS CRASHING

“Is this really true?” my editor at Beacon Press emailed me skeptically. It was a spring afternoon in 2016 and she had tacked on an article from the British Medical Journal (BMJ) that caused headlines in the mainstream media (though it stirred up a healthy dose of criticism in academic circles).1 Medical error, the article concluded, was the third-leading cause of death in the United States.

I floundered for an answer to her question, and not just because I hadn’t been keeping up with the medical journals that pile up relentlessly in my clinic, in my mailbox, in my inbox, and, okay, even in my bathroom. I floundered because I genuinely could not answer her question. Third-leading cause of death? Really? Did medical error really beat out breast cancer, stroke, Alzheimer’s disease, accidents, diabetes, and pneumonia?

As a practicing internist for the past twenty-five years at Bellevue Hospital, one of the largest and busiest hospitals in the United States, I feel as though I see a reasonable cross-section of medicine today. My patients suffer overwhelmingly from the ailments of a twenty-first-century “developed” society—obesity, diabetes, heart disease, hypertension, cancer.

If medical error is the third-leading cause of death, then I should be seeing it all the time, right? I should be hearing about it from friends and family. If medical error clocks in just after heart disease and cancer as a killer, it should be part of my everyday medical experience.

But it isn’t.

Or at least it doesn’t feel that way.

I have witnessed medical errors, of course, and I’ve certainly made my share of them. I’ve heard bone-chilling tales in hospital corridors and read shocking, heart-wrenching stories in the media. Yet these all feel like exceptions—rare and horrible. These deaths don’t pop up in my clinical practice with a frequency remotely near that of congestive heart failure, lung cancer, or emphysema.

Yet the data keep coming. From the first Institute of Medicine report in 19992 that estimated 44,000 to 98,000 deaths per year from medical error to this BMJ analysis suggesting upward of 250,000 deaths per year—medical error seems on the verge of a public health emergency. Even if the numbers aren’t completely precise—the methodologies of these papers have been challenged—researchers are in agreement that the number of errors is not small at all.

Are the data wrong? Or am I wrong?

Am I—and most medical staff—simply not seeing this epidemic? Are we biased? In denial? Are we clinicians killing our patients at an unprecedented rate and somehow remaining blithely unaware? If that’s really the case, perhaps we should take down our collective shingles and spare our patients the damage. We could just tack a note onto the door: “Eat quinoa and beans. Take the stairs. Stay away from the healthcare system.”

While the “third leading cause of death” claim is likely an overstatement, there is definitely a yawning gap between the published statistics of medical error and the experience of the everyday clinician. And then there are the experiences of the everyday patient, which also diverge from the data but in different ways.

As a practicing physician—and an occasional patient myself—I feel I have to get to the bottom of this. What I experience and what the published data conjecture seem at complete odds. One of us is calling it wrong, and my goal is to find out who…

Ofri, Danielle (2020-03-31T23:58:59.000). When We Do Harm. Beacon Press. Kindle Edition.

FanBoy.
 

After QIO retirement, I continued on for several years covering the (mostly Silicon Valley) Health IT startup space. But, now I'm just a cranky retired 77 yr-old patient with Parkinson's, no longer up-to-date competent to opine on the status of EHRs.

 

I sure had my fun. Here as well. “There’s a whole lot of things that I never done, but I ain’t never had too much fun.” For example, from a prior post in June 2019:

 

CLINIC MONKEY ERRATUM

Back when I was working for the HealthInsight REC ("Meaningful Use" program) I routinely bit the hand that fed me when I felt it was warranted. Among other irreverent things, I posted a spoof "Certified EHR" site I called "Clinic Monkey" (tangentially riffing on Survey Monkey, which we used all the time).

When I put it up I embedded "under the hood" an mp3 autoplay endless loop file of ambulance sirens and jungle critters screeching and yacking, for comic effect. No longer works in Safari. I think it's an html thing, no longer supporting the old legacy "embed code." Whatever. It was funny.

One morning I got to the office and found a toy set of simian "office workers" on my chair. One of my colleagues had bought it for me. A Clinic Monkey admirer, no doubt.

Off to the garage I go forthwith after work.

BobbyG's on-the-fly Dollar Store photoshoot cyc.

Yeah, I have an Attitude. One frowned upon by the Really Serious (and snark-challenged) People. It's OK to lighten up.

 

ALL JOKING ASIDE: DR. OFRI ON THE EMR

…One morning in my clinic, as I was seeing my first patient of the day, I noticed that the electronic medical record (EMR) looked a little different. Apparently there had been some sort of “rollout” of various updates in the wee hours of the night, and now a bunch of minor things were out of order and tripping me up.

My fingers automatically knew, for example, that Spanish was #41 when it came to the language spoken by the patient, since Spanish is our most common second language. Knowing the number by heart saved me the aggravation of scrolling through the whole list. But somehow in this rollout, another language had been added, bumping Spanish to #42. My fingers still went to #41, though, so every patient that day came out speaking Serbian.

And then all of sudden, three brand-new fields popped up that I’d never seen before: latex allergies, food allergies, and environmental allergies. We’d always had a required allergies field, and you could enter any kind of allergy—medication allergies, food allergies—or even free-text other kinds of allergies (a few times I’d been tempted to write in “EMR allergy,” but I restrained myself). But now these three new required fields popped up, and they each demanded my attention.

Now, it’s not that I think latex, food, and environmental allergies are unimportant, but their inopportune debut made a hard day even harder. I typically type most of my notes after the patient has left the room, to avoid having the computer be the focus of a visit. So now I would encounter those new fields and face the prospect of sprinting out to flag down patients before they entered the elevator, hollering incoherently about latex gloves, kiwi fruits, and cat dander, smack in the middle of a day when everyone was suddenly speaking Serbian.

I recognized that these additional fields in the EMR were interventions to prevent medical error. They were placed there as part of a well-meaning effort on behalf of our patients to avoid using latex gloves if they were allergic or to make sure the staff didn’t inadvertently deck the halls with boughs of ragweed during holiday season. But I found myself incensed by the whole process. The hospital was already using latex-free gloves, so the potential yield on that effort was distinctly low. But filling in these boxes took away time from focusing on things such as diabetes and heart disease that were really posing threats to my patients’ safety.

You can be sure there was a 100% compliance rate on this effort—it was a required field, so no doctor could close out a note until something had been entered. Somewhere in some office there was a midlevel manager proudly reporting to his supervisor that the medical staff was “100% compliant.” Did this effort actually advance the cause of patient safety in our hospital? I highly doubt it, since nearly everyone gave up in frustration and just clicked “no” to the latex allergy question (and faked the food and environmental allergy questions as well).

At the time I viewed this whole episode as just one more EMR annoyance and one more example of bumbling administration. But after reviewing the experience with checklists, I can see it as an implementation disaster. It was a laudable patient-safety intervention that lacked even the slightest attention to implementation. We had not been given any heads-up that we’d have to start asking patients about latex allergies or that our Hispanic patients would start yammering away in Serbian. No one thought through the unintended consequences of rejiggering the workflow that hundreds of doctors were doing automatically. No one thought about the time it would take. No one seemed to weigh the potential value of this intervention in a hospital that does not use latex gloves. (Yes, there are some latex catheters, but gloves are the overwhelming source of latex.) No one asked whether the juice was worth the squeeze.

This approach to allergies illustrates how checklists can become victims of their own success. Once you start checklisting everything, it devolves into checklist overload. One of the reasons the central-line and surgical checklists worked well was that they were the only checklists on the block. Once you have dozens in play, doctors and nurses can’t cope. There are so many things to check off that you can hardly take care of your patients. Everyone just checks off everything to make it all go away. It’s not necessarily a deliberate gaming of the system; it’s a survival mechanism. A number of lessons can be gleaned from these initial forays into decreasing medical error and improving patient safety. One is that you have to address the system as a whole; piecemeal efforts get you only so far. Another is that if you overemphasize “100% compliance,” you will most certainly end up with people gaming the system, even if they aren’t doing it with malicious intent… [Ofri, pp. 13-15]

Ouch. Yeah. I know this kind of stuff all too well.

__________

 

Exploiting Doctors and Nurses

Danielle Ofri, MD, in the New York Times:

…If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.

The demands on medical professionals have escalated relentlessly in the past few decades, without a commensurate expansion of time and resources. For starters, patients are sicker these days. The medical complexity per patient — the number and severity of chronic conditions — has steadily increased, meaning that medical encounters are becoming ever more involved. They typically include more illnesses to treat, more medications to administer, more complications to handle — all in the same-length office or hospital visit.

By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system.

There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients.

In a factory, if 30 percent more items were suddenly dropped onto an assembly line, the process would grind to a halt…

Read the entire piece. I've cited Dr. Ofri on numerous occasions and have read her books and articles.

 

The E.M.R. is now “conveniently available” to log into from home. Many of my colleagues devote their weekends and evenings to the spillover work. They feel they can’t sign off until they’ve documented all the critical details of their patients’ complex medical histories, followed up on all the test results, sorted out all the medication inconsistencies, and responded to all the calls and messages from patients. This does not even include the hours of compliance modules, annual mandates and administrative requirements that they are expected to complete “between patients.”

According to their latest available IRS 990 (2017), the CEO of the Health Information Systems Management Society "non-profit" trade association (HIMSS) is paid about $1.25 million a year. I'm sure he's a very busy person.

As must also be the CEOs of Johnson & Johnson and Pfizer, each of whom earn close to $30 million annually.

The average primary care doc makes about $225k, according to Medscape.

AN ICONIC GRAPHIC

Yeah, it's a decade old. I'm confident that the trend has neither flattened nor reversed.

UPDATE

Monday morning rounds. Saw this cited at The Incidental Economist:

What makes us healthy?
 
We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”

How much do social determinants matter? How much does the health system improve our health?

Certainly worth following. 'The Drivers."

A theme I'll be hitting a few times is that to what we attribute health changes over time. It's not possible to say it's x% this and y% that *forever*. More on the @DriversofHealth blog: https://t.co/2buIV4l300 #SDoH pic.twitter.com/KQRmc1zekz

— Austin Frakt (@afrakt) June 7, 2019

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More to come...

"There is no way to survive the coming rise in Medicaid recipients, aging boomers, still-uninsured and underinsured without a lean, efficient organization." - Joe Flower

One of the clearest thinkers in the health care space is Joe Flower. His latest blog post "What about the poor?" is a tour de force. An excerpt:

What can we expect in the coming years?

The Future of Medicaid, the Uninsured and the Underinsured

Medicaid numbers are astonishing if you are not used to them. Even before the projected expansion, at some time during an average year about 72 million people, close to a quarter of all Americans, are on Medicaid. At any given moment, it’s over 50 million. Medicaid is an open-ended program: When more people are eligible, or sick, or have more complex diseases, the states and the federal government pay more. By law, states have to provide certain minimum benefits for certain defined poor populations, such as children, pregnant women, the disabled and the elderly. The only control states have over Medicaid costs is to cut reimbursements and to control utilization by making health care massively inconvenient to access.

The economy. The economy appears to have undergone real structural change. In this new economy a lower proportion of the working age population is able to find work with a living wage or start a sustaining business. Income inequality is still growing, with almost all of the new wealth created in the slowly recovering economy going to those few who are already well off. So we can expect more Medicaid-eligible people every year.

Expansion. In over half the states, Medicaid eligibility has been expanded by the Affordable Care Act (ACA) to include all adults with income below 138 percent of the federal poverty level (FPL). More states will likely accept the expansion. Turning away federal money that would benefit your citizens and pay for thousands of jobs (as studies show) may be ideologically pure, but politically and economically it is a very shaky stance. It will become shakier as people in neighboring states reap the benefits, while yours do not.

Will those newly covered individuals use more health care or less? Contrary to a common assumption, studies show that just getting people covered does not in itself improve their health, and those newly insured patients will likely use the emergency department (ED) 40 percent more than they did when uninsured, unless the system finds some less expensive way to serve their needs. The “system,” in this case, is you.

Underinsured. The ACA will actually expand the ranks of the underinsured (those whose insurance is weak enough that they will often act as if they are uninsured). The “bronze” plans cover only 60 percent of most expenses; the “silver” only 70 percent, well below the 80 percent typical of corporate plans, with much higher deductibles. The feds also allow, in fact encourage, states to add deductibles and co-pay requirements to Medicaid even for the poorest. And many states that are expanding eligibility are actively cutting reimbursements, narrowing networks and reducing benefits.

Out-of-luck demographics. At the same time many people, especially in the just pre-Medicare demographic, will not want to accept Medicaid, because they still have some assets, typically equity in a house, that Medicaid would require them to liquidate and “spend down.” In the states that do not expand Medicaid eligibility, the uninsured non-disabled adult below 138 percent of the FPL is just plain out of luck, with no ACA subsidies for insurance, but is still hit with the ACA tax penalty.

So expect still substantial numbers of uninsured — 26 million by 2016 by Congressional Budget Office estimates — as well as growing Medicaid rolls in all states, even those that do not expand eligibility.

Reform? “Deficit hawk” politicians focus on Medicaid because it is growing and open ended. Proposals to reform Medicaid largely would make it into block grants to the states, which Congress could then throttle downward. No proposed reforms contemplate putting more money into Medicaid. Under any reasonably expectable political scenario we can expect ever-narrowing reimbursements.

Health care execs can be forgiven for feeling that they are in some zombie movie, pursued by teeming masses of people with Medicaid coverage, or no coverage at all. But it’s time to stop hiding. It’s time to leave behind the old tactics of divert, dump and deny once and for all, and to push instead for radical new ways of providing health care — good, quality care — to those who can least afford it...

Click the link above. Read the entire piece. I've forwarded it on to Dr. John Toussaint of the ThedaCare Center.

I began this blog nearly four years ago touting the utility of "Lean" right in my first post. See also one of my workflow slide decks (pdf).

apropos of the title of Joe's post, "What about the poor?" recall my prior post “When it comes to health, your zip code matters more than your genetic code.”

See also Danielle Ofri's latest:

When Doctors Give Patients Money
By DANIELLE OFRI, M.D.

Recently a few of my colleagues were sitting together and one asked if any of us had ever given money to a patient. There was an awkward pause, and then the stories starting coming out — a few dollars for a co-pay, or to help a frail patient take a cab instead of a bus; a bag of food or an extra meal. “How could I not,” one doctor said, “when my patient’s immediate need could be solved by the small change in my coat pocket?”

A physician recently wrote in JAMA about giving a patient $30 to help pay for a medication after a two-hour phone battle with the insurance company came to naught. He was cited by his institution for unprofessional behavior, but was also deluged with letters from doctors and nurses who have been in the same position and done the same thing.

We hear daily about “health care costs,” a lumbering behemoth that dominates the news and the economy. But it is the smaller amounts, literally the pocket money, that often has the most profound and palpable effect on the concrete currency of health.

Caregivers on the front lines fully recognize that giving patients a few dollars isn’t ultimately the way to solve the problems of society. But the starkness of our patients’ immediate needs are hard to ignore...

Even though overall health care costs have been falling slightly, and some aspects of the economy appear to be improving, economic realities are playing an increasing role in the day-to-day health of many patients. The dollar amounts in question are usually small — bundled together they would hardly rise to a rounding error of a distant decimal of “health care costs.” The impact, however, is anything but small. Medications skipped, antibiotics delayed, procedures avoided, diet skimped — the morbidities rack up quickly.

A recent study in Health Affairs confirmed what most physicians and nurses see in their daily practice — lack of small amounts of money wreaks outsize damage on health. This particular analysis showed that in low-income neighborhoods there was a 27 percent increase in hospital admission for hypoglycemia, or low blood sugar, at the end of the month compared with the beginning of the month.

This end-of-the-month disparity, unsurprisingly, was not noted in high-income neighborhoods, where households do not run out of money and food at the end of the month...

Yeah. See also

Millions Are Now Realizing They're Too Poor For Obamacare

Thanks to a Supreme Court ruling and staunch Republican resistance, Marc Alphonse, an unemployed 40-year-old Marine veteran who is essentially homeless, cannot get health insurance under Obamacare.

Three years ago, Alphonse learned he has a kidney disorder that will deteriorate into kidney failure, and possibly prove fatal, if left untreated. As it stands now, he suffers from bouts of nausea caused by his dysfunctional kidneys, and he's dogged by an old knee injury that limits his job prospects. He gets by on $400 a month in unemployment benefits, and his family can no longer afford housing in their home city of Miami. Alphonse's 28-year-old wife, Danielle, and three young children are staying with relatives while Alphonse couch surfs.

"I live from family to family until I'm able to get myself situated," he told The Huffington Post.

Alphonse is one of nearly 5 million uninsured Americans caught in a cruel gap that renders some Americans "too poor for Obamacare."

Broken Promise

Obamacare was supposed to make health coverage affordable, or even free, for low-income Americans. The law's official name is the Affordable Care Act. However, the Supreme Court tossed a huge obstacle in the path of that goal in 2012, ruling that the states could opt out of one of Obamacare's crucial provisions: The expansion of Medicaid coverage to anyone making less than 133 percent of the federal poverty level, or about $15,300 a year for a single person. Since the court's ruling, 24 states, including Florida, chose not to expand the program...

Indeed. "What about the poor?"
___

More to come...

Update on our favorite whipping boy, the EHR

From Trump's "failing NY Times" (I finally ponied up and subscribed, along with forking over at WaPo):

There are times when the diagnosis announces itself as the patient walks in, because the body is, among other things, a text. I’m thinking of the icy hand, coarse dry skin, hoarse voice, puffy face, sluggish demeanor and hourglass swelling in the neck — signs of a thyroid that’s running out of gas. This afternoon the person before me in my office isn’t a patient but a young physician; still, the clinical gaze doesn’t turn off, and I diagnose existential despair.

Let’s not call this intuition — an unfashionable term in our algorithmic world, although there is more to intuition than you think (or less than you think), because it is a subconscious application of a heuristic that can be surprisingly accurate. This physician, whose gender I withhold in the interest of anonymity and because the disease is gender-neutral, is burned out in what should be the honeymoon of a career. Over the years, I have come to recognize discrete passages in a medical life, not unlike in Shakespeare’s “Seven Ages of Man” — we have our med-school equivalent of “the whining schoolboy with his satchel and shining morning face” and the associate professor “jealous in honor, sudden and quick in quarrel.” But what I see in my colleague is disillusionment, and it has come too early, and I am seeing too much of it.

Does this physician recall sitting before me as an idealistic first-year medical student, keen to take the world in for repairs? It was during those preclinical years that the class learned to use the stethoscope, the ophthalmoscope and the tendon hammer, to percuss the body, sounding out its hollows, the territorial boundaries of lung and liver. After the preclinical come the two clinical years, though I think of those phases these days as precynical and cynical. When students arrive on the wards full time, white coats packed with the aforementioned instruments, measuring tape, tuning fork, flashlight and Snellen eye chart, they are shocked to find that the focus on the ward doesn’t revolve around the patients but around the computers lining the bunkers where students, residents and attending physicians spend the majority of their time, backs to one another. All dialogue among them and other hospital staff members — every order, every lab request and result — must pass through this electronic portal, even if the person whose inbox you are about to overload is seated next to you.

In America today, the patient in the hospital bed is just the icon, a place holder for the real patient who is not in the bed but in the computer. That virtual entity gets all our attention. Old-fashioned “bedside” rounds conducted by the attending physician too often take place nowhere near the bed but have become “card flip” rounds (a holdover from the days when we jotted down patient details on an index card) conducted in the bunker, seated, discussing the patient’s fever, the low sodium, the abnormal liver-function tests, the low ejection fraction, the one of three blood cultures with coagulase negative staph that is most likely a contaminant, the CT scan reporting an adrenal “incidentaloma” that now begets an endocrinology consult and measurements of serum cortisol.

The living, breathing source of the data and images we juggle, meanwhile, is in the bed and left wondering: Where is everyone? What are they doing? Hello! It’s my body, you know!…

My young colleague slumping in the chair in my office survived the student years, then three years of internship and residency and is now a full-time practitioner and teacher. The despair I hear comes from being the highest-paid clerical worker in the hospital: For every one hour we spend cumulatively with patients, studies have shown, we spend nearly two hours on our primitive Electronic Health Records, or “E.H.R.s,” and another hour or two during sacred personal time. But we are to blame. We let this happen to our trainees, to ourselves.

How we salivated at the idea of searchable records, of being able to graph fever trends, or white blood counts, or share records at a keystroke with another institution — “interoperability”! — and trash the fax machine. If every hospital were connected, we would have a monster database, Big Data that’s truly big and that would allow us to spot trends in disease so much earlier and determine best practice and predict complications. But we didn’t quite get that when, as part of the American Recovery and Reinvestment Act of 2009, $35 billion was eventually steered toward making medicine paperless.

My A.T.M. card is amazing: I can get cash and account details all over America and beyond. Yet I can’t reliably get a patient record from across town, let alone from a hospital in the same state, even if both places use the same brand of E.H.R., for reasons that are only partly explained by software that has been customized for each site. This is not like sending around a standard Word file. And so, too often the record comes by fax.

What the E.H.R. has done is help reduce medication errors; it is a wonderful gathering place for laboratory and imaging information; the notes are always legible. But the leading E.H.R.s were never built with any understanding of the rituals of care or the user experience of physicians or nurses. A clinician will make roughly 4,000 keyboard clicks during a busy 10-hour emergency-room shift. In the process, our daily progress notes have become bloated cut-and-paste monsters that are inaccurate and hard to wade through. A half-page, handwritten progress note of the paper era might in a few lines tell you what a physician really thought. (A neurosurgeon I once worked with in Tennessee would fill half the page with the words “DOING WELL” in turquoise ink, followed by his signature. If he deviated from that, I knew he was very worried and knew to call him.) But now, with a few keystrokes, you can populate your note with all the listed diagnoses, all the medications, all the labs, all the radiology reports, pages and pages of these, as well as enough “smart phrases” — “.EXT2” might spit out “Extremities-2+ pedal edema, normal pulses” — to allow you to swear you personally examined the patient from head to foot and personally took all the elements of the history, personally did a physical exam separate from the admitting physician that would put Sir William Osler to shame, all of which make it possible to bill at the highest level for that encounter (“upcoding”)...

"For every one hour we spend cumulatively with patients, studies have shown, we spend nearly two hours on our primitive Electronic Health Records..."

I'm still having trouble believing that. It is, however, an empirical matter, vague "studies have shown" anecdotes aside. (See, e.g., my 2014 riff on data-mining the EHR security logs for workflow analytics.)

Read the entire NY Times piece.

apropos, see a couple of my prior posts: "Are structured data the enemy of  health care quality?" and "Clinical cognition in the digital age."

And, of course, we musn't forget English major @Healthcare_Kate's swell "EHRs are a dying technology."

The NY Times article headline cites 'Machine Learning." But, I've noted possible "reproducibility problems."

Finally (for now). see my post "Fix the EHR?" Of course, but how about fixing the clinical process workflows?

ERRATA

Five weeks since my daughter died. Still seems like last night. Sigh...

Next up for me? The SAVR px. Just thrilled. Meeting with my Primary and my Cardiologist tomorrow, then the Cardiac Surgeon next Tuesday. I had a coronary angiogram done. Negative for blockages, so I'm looking at "just" a straight aortic valve job.

BTW, Danielle's former employer has launched the Danielle L. Gladd Scholarship Fund in her honor and memory. I just contributed.

UPDATE

Another cautionary tale regarding medical charts, this one having zilch to do with keystrokes and mouse clicks.

Your Medical Chart Might be Biased. Here’s What Doctors Should Do About It.
Racial disparities in health outcomes are complicated, but this is one place to start.
By DANIELLE OFRI

…A recent paper caught my eye because it captured one of the more subtle aspects of the brew: how we write about patients in the chart. Mary Catherine Beach and her colleagues at Johns Hopkins University were curious about whether our choice of language transmits bias from one medical professional to another. The researchers created a hypothetical case of an African American man with sickle cell disease, a condition that typically requires opiate medications for control of painful flares. They wrote two versions of the medical chart, one with neutral language and one with language—taken from real charts—that could be viewed as more stigmatizing. Medical students and residents were randomized to read one of the charts and then asked about their attitude toward the patient and how much pain medication they would prescribe.

Those trainees who read the chart with the more stigmatizing language exhibited more negative attitudes toward the patient and elected to give less aggressive pain treatment. This result is probably not surprising—we know that black patients tend to receive lower rates of pain treatment. But what is intriguing is how subtle the differences in language were between the two charts. In the first chart, the patient was described as a “28-year old man with sickle cell disease” and in the second chart as a “28-year old sickle cell patient.” Before the symptoms occurred the patient “spent yesterday afternoon with friends” versus “was hanging out with friends outside McDonalds.”

For the physical examination, the doctor observed in the first chart that the patient “is in obvious distress,” and in the second that the patient “appears to be in distress.” A nursing note in the first chart reported that the patient “is not tolerating the oxygen mask and still has 10/10 pain,” and in the second chart that the patient “refuses to wear his oxygen mask and is insisting that his pain is ‘still a 10.’ ”

The descriptions in the second chart weren’t necessarily inaccurate, but together they subtly paint the patient as a less reliable person, someone who perhaps is trying to game the system for drugs. According to Beach, this type of language not only discredits the patient’s report of pain, but highlights details that reinforce negative stereotypes. Medical charts are the primary means of communication among medical professionals, so this sort of language covertly signals to other members of the team that this is a ‘low class’ person who isn’t trustworthy or deserving.

As soon as Beach put it this way, I could see that our supposedly objective medical records contain racially laden dog whistles of the sort that we regularly decry in political speech. In the last two years we’ve gotten more adept at noticing and calling out references to inner cities, illegal aliens, international bankers, Sharia law, and locker-room talk, but we doctors like to think that we treat all our patients equally. We would never think of ourselves as racist or marginalizing. Yet, it’s there in our language…

Seriously doubt that digital "AI/NLU" (Natural Language Understanding) tech portends any help there.

I love Dr. Ofri's work, and have cited her many times.

Numerous relevant Danielle Ofri articles up on Slate, btw.

I'd like to know what Rachel Pearson ("@HumanitiesMD") thinks about the foregoing. I keep bugging her about wanting to read her Doctoral Dissertation, to no avail as yet. "You must be the only person in the country who wants to read it."

Summary of Dissertation:

Objectivity is an epistemological virtue that physicians aspire to embody in our practice. Historians and philosophers have pointed out that objectivity is culturally specific: it varies with time, place, and profession. In pre-clinical training, physicians learn to honor a scientific version of objectivity, in which the self is understood primarily as a potential source of error and “scientific selves” seeks to eradicate the pernicious influence of the self from scientific data. In practice, however, this research identifies that medical objectivity is distinct from scientific objectivity. This dissertation examines memoirs of medical training to understand how physician trainees learn, experience, and use objectivity...

All part of a piece, 'eh?
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More to come...

Questioning "Innovation?" Is that even allowed?

From one of my favorite requisite daily hangs.

The commentariat is every bit the equal of the topical authors. Better bring your A-Game if you're gonna participate; they do not suffer fools gladly. ("Yves Smith" is the blog owner.)

Questioning Innovation
Posted on December 5, 2019 by Yves Smith

I haven’t quite worked through my reaction to some recent pieces in the Financial Times that seem to merit comment, so forgive me for picking out a just a couple of tidbits that still might serve as grist for discussion.

One thing that has long bothered me is the worship of innovation. Relatively early in my career, I had a consulting gig with a venture capital firm where my job was to look at oddball deals. I learned that quite a few bona fide inventions and technology improvements, even though they might seem cool and engineers would get excited about them, didn’t add up to a business opportunity. The most common failing was they didn’t represent a big enough improvement over the status quo to justify customers making the needed behavior changes to adopt them.

And an even earlier lesson came in college, when I majored in the history and literature of the modern era, which meant the Industrial Revolution to World War II. The first generation, and arguably even two, of the Industrial Revolution led to a decline in worker incomes in England. The revolutions of 1848 were mass pushback against the dislocations of the rise of factory work. So while industrialization eventually increased living standards, the transition costs exacted a great toll on laborers who didn’t live long enough to reap the benefits. And we are now suffering the long-term cost of environmental degradation…

If one wants to get worked up about the US actually being a laggard or being at risk of becoming one, it’s a little late to get worked up now. How about what passes for Silicon Valley talent focusing on….help me…apps? How about our slow and overpriced broadband? How about our generally terrible infrastructure, which is imposing a cost on citizens and businesses on a broad basis? America’s lifespan is falling, and the priority is 5G?

The reason I am increasingly a Luddite is I see too much use of technology to curtail our economic rights and even now our supposed ownership, or otherwise enable better rentierism…

Technology is working towards the creation of a new debt cropper society. It may not get anywhere near as far as it did in the Reconstruction Era, but having to pay and pay and pay (then via jacked up financing charges, now via restricted ownership rights leading to unnecessarily high costs, particularly from having to replace consumer durables more often or pay high authorized servicer repair costs), but the trend is underway…

Read all of it, including the accruing comments.

"Rentierism." I am reminded of Quadrant II of Frase's Four.

Also, buy and study Yves' excellent book. One of my FIRE Sector favs (in which I did a 5-yr tenure).

The economy is far too important to all of us to leave to experts, particularly when their recommendations often have little in the way of empirical foundations. Both experts and charlatans rely on intimidation, such as the use of arcane (even if useful) terminology and a dismissive attitude to deter reasonable queries. We all need to get in the habit of demanding support, not sound bites or sixth-grade level opinion pieces, but reasoned and complete explanations of why economists believe what they believe. That was the reason for adopting mathematical exposition in the first place, to make the logic and evidence behind their reasoning explicit and transparent. It’s time they adopt that standard for communication with the public. [Ch 9, location 6551]

INNOVATION REMINISCENCE: THE ROTARY DIAL PHONE

 LOL...

THE EHR: "INNOVATIVE" OR OBSTRUCTIVE

Patients vs Paperwork
by Danielle Ofri
New York Times

Every doctor I know has been complaining about the growing burden of electronic busywork generated by the EMR, the electronic medical record. And it’s not just in our imaginations.

The hard data have been rolling in now at a steady pace. A recent study in the Annals of Family Medicine used the EMR to examine the work of 142 family medicine physicians over three years. These doctors spent more than half of their time — six hours of their average 11-hour day — on the EMR, of which nearly an hour and a half took place after the clinic closed.

Another study in Health Affairs tracked the activities of 471 primary care doctors over a three-year period, and also found that EMR time edged out face-to-face time with patients.

This study came on the heels of another analysis in the Annals of Internal Medicine in which 57 physicians were observed directly for 430 hours. These researchers found that doctors spent nearly twice as much time doing administrative work as actually seeing patients: 49 percent of their time, versus 27 percent.

These study results hovered over my head as I worked through a recent clinic session, most of which felt devoted to serving the EMR rather than my patients. It was the kind of day that spiraled out of control from minute one, and then I could never catch up. The kind of day, nowadays, that is every day.

Part of the issue is that there are simply more patients, most of whom are living longer with many more chronic illnesses, so each patient has much more that needs to be taken care of in a given visit.

But the main reason that I can’t keep up is the EMR. Like some virulent bacteria doubling on the agar plate, the EMR grows more gargantuan with each passing month, requiring ever more (and ever more arduous) documentation to feed the beast…

Yeah. That hardy perennial lament. Can't argue with the beef--except to assert that it's not the technology per se, it's the incumbent business paradigm. "Patients vs Paperwork." Interesting choice of words. I assume Dr. Ofri isn't advocating a return to actual paper recordkeeping.

Although, my friend Margalit might disagree.

Relatedly, on the "business paradigm" of health care policy:

The American Health Care Industry is Killing People

Yes, transitioning to a more equitable system might eliminate some jobs. But the status quo is morally untenable.

Won’t you spare a thought for America’s medical debt collectors? And while you’re at it, will you say a prayer for the nation’s health care billing managers? Let’s also consider the kindly, economically productive citizens in swing states whose job it is to jail pregnant women and the parents of cancer patients for failing to pay their radiology bills. Put yourself in the entrepreneurial shoes of the friendly hospital administrator who has found a lucrative new revenue stream: filing thousands of lawsuits to garnish sick people’s wages.

And who can forget the lawyers? And the lobbyists! Oh, aren’t they all having a ball in America’s health care thunderdome. Like the two lobbyists who were just caught drafting newspaper editorials for Democratic state representatives in Montana and Ohio, decrying their party’s push toward a “government-controlled” health care industry. It’s clear why these lobbyists might prefer the converse status quo: a government controlled by the health care industry. If we moved to a single-payer system, how would lobbyists put food on the table, and who would write lawmakers’ op-ed essays?

Welcome to the bizarre new argument against “Medicare for all”: It’s going to cost us jobs. Lots of jobs. Good, middle-class, white-collar jobs in America’s heartland, where Democrats need to win big to defeat Donald Trump…

Hmmm... From a prior post.

I am reminded of a passage from a David Graeber book:

wherein he asks,

Does this mean that members of the political class might actually collude in the maintenance of useless employment? If that seems a daring claim, even conspiracy talk, consider the following quote, from an interview with then US president Barack Obama about some of the reasons why he bucked the preferences of the electorate and insisted on maintaining a private, for-profit health insurance system in America: 

“I don’t think in ideological terms. I never have,” Obama said, continuing on the health care theme. “Everybody who supports single-payer health care says, ‘Look at all this money we would be saving from insurance and paperwork.’ That represents one million, two million, three million jobs [filled by] people who are working at Blue Cross Blue Shield or Kaiser or other places. What are we doing with them? Where are we employing them?”

I would encourage the reader to reflect on this passage because it might be considered a smoking gun. What is the president saying here? He acknowledges that millions of jobs in medical insurance companies like Kaiser or Blue Cross are unnecessary. He even acknowledges that a socialized health system would be more efficient than the current market-based system, since it would reduce unnecessary paperwork and reduplication of effort by dozens of competing private firms. But he’s also saying it would be undesirable for that very reason. One motive, he insists, for maintaining the existing market-based system is precisely its inefficiency, since it is better to maintain those millions of basically useless office jobs than to cast about trying to find something else for the paper pushers to do. 

So here is the most powerful man in the world at the time publicly reflecting on his signature legislative achievement—and he is insisting that a major factor in the form that legislature took is the preservation of bullshit jobs…

Graeber, David. Bullshit Jobs: A Theory (p. 157). Simon & Schuster. Kindle Edition.

'eh?

WEEKEND UPDATE, MORE NAKED CAPITALISM

Financialization of the U.S. Pharmaceutical Industry
Posted on December 7, 2019 by Yves Smith

 

Yves here. This article is a bit geeky but very much worth your attention. It shows how pharmaceutical companies are flat out lying when they say they need higher drug prices to support R&D. Their profits go almost entirely to buybacks and dividends. And this analysis does not incorporate another unflattering fact: that Big Pharma spends more on marketing than research. It also describes how government funding of drug research has increased more than three times in real terms since the 1980….as executives have lined their pockets.

The authors make a short set of recommendations at the end, starting with regulating drug prices...

NC rocks. Again, be sure to always read the comments.

From the post:

Perhaps no business activity is more important to our well-being than the discovery, development, and distribution of medicines. Unfortunately, many of the largest U.S. pharmaceutical companies have become global leaders in financialization at the expense of innovation. Drug prices are at least twice as high in the United States as elsewhere in the world.

Over the decades, pharmaceutical companies have lobbied vigorously against proposed market regulations designed to control drug prices in the United States. The main argument that the industry’s lobby group, the Pharmaceutical Research and Manufacturers of America (PhRMA), habitually makes against drug-price regulation is that the high level of profits that high drug prices make possible in the U.S. drug market enables pharmaceutical companies to be more effective in drug innovation…

Rx "Innovation." Yeah, right.

OFF-TOPIC PERSONAL ERRATUM

Hope draws nigh, scheduled to arrive this Christmas Eve. Hope Eleanor Nyquist, my first Great Niece, daughter of my awesome Niece April, wife of Neurotrainer.com CEO and Chief Scientist Dr. Jeff Nyquist.

I shot this--and a couple hundred more--at their wedding.

ANOTHER QUICK PERSONAL NOTE

I am remiss in not citing the Hopewell Cancer Support center here in the Baltimore area.

Gave 'em a permanent upper right-hand links column link (click the image). Looked up their most recently available IRS 990. Looks totally legit. They're only maybe 5 miles from our house. Will have to pay them a visit, looks for ways to help.

Tangentially, saw this discussed recently on TV and bought the book.

Our grief can’t just be buried alongside the ones we love. Even years after our losses, we still have moments of gut-wrenching sadness. We’re still annoyed by a wide variety of major and minor Hallmark holidays. We still get pissed thinking about the hand we’ve been dealt. But guess what? 

These days, we’re tagging family members on Instagram. They’re just not the ones we thought we’d be tagging—and ones that in our darkest moments we never thought would be in our lives. 

Eventually, we’re all going to lose people we love. Eventually, we’re all going to die. This is true whether or not we admit it to each other. So there’s value in building a community where there’s no stigma to talking about death and the countless ways it impacts our lives. And with this book, and the candor of those who contributed to it, we hope to open up the conversation so that, ideally, in the future, nobody has to hear crickets in the face of a loss.

Soffer, Rebecca. Modern Loss (pp. xxiii-xxiv). Harper Wave. Kindle Edition.

Haven't read much of it yet, but I will shortly and review it. Been rather sick of thinking about cancer and loss this year. My grief, while manageable, is permanent. I'm absolutely sure I'm not alone.
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More to come...