D.C. Circuit guts ObamaCare

[JollyRoger]

A physician I know can do quite a bit in 9 minutes - not even the Urban Dictionary can keep up with her antics.

 

[Crackerbox]

A physician I know can do quite a bit in 9 minutes - not even the Urban Dictionary can keep up with her antics.

Yeah, getting crap done in 9 minutes all day long, even for 2.5 days straight as some residents do, well that's expected. But they can also be sued for what they did while so exhausted that it's been compared to being inebriated. It's criminal to force them to do this as some sort of rite of passage, or to expect the patient is getting any quality of care, and then for there not to be loads and loads of medical errors.

Spoiler :

The Accreditation Council on Graduate Medical Education requires all training programs to "...educate faculty and residents... to recognize the signs of fatigue...and adopt and apply policies to prevent and counteract the potential negative effects." Examples of such policies include, specialty -specific duty hour requirements such as maximum of 80 duty hours per week, in-house call no more frequently than one in three nights, a minimum of one 24-hour period off each week, a minimum of 10 hours free between consecutive duty periods, and duty periods of no more than 24 hours with up to an additional 6 hours for continuity or education.

The American Medical Association Council on Ethical and Judicial Affairs considers physicians attending to their own health and wellness, as well as the health of their colleagues, an ethical imperative.

Compliance with duty hours is monitored. Residents are urged to report any concern regarding duty hours, fatigue, and other issues to the GME Office.

Parallel to the focus on "duty hours" are efforts to increase the awareness of fatigue's impact on trainee well-being, learning, and patient safety. These include dissemination of:
■Evidence-based information regarding the prevention, recognition and management of fatigue
■Awareness of institutional sleep experts and options
■Access to national and specialized resources

Restricting duty hours alone does not preclude fatigue. Of particular concern, is that the very strategies that training programs may adopt in a good faith effort to adhere to the 80-hour work week may result in unintended adverse consequences. Programs may feel their work is "done" if they demonstrate compliance with duty hours standards, even though 80 hours is twice the work week duration of the average employed American. Programs may miss identifying persistent fatigue.

Although perhaps better rested, resident stress may increase if residents are concerned about losing significant learning opportunities, procedural experience, and interaction with colleagues. Residents may feel trapped by competing demands between work hours and professionalism. They may feel support is lacking from senior residents and faculty who may have an inadequate understanding of this mandate and perhaps are resentful of restrictions on duty hours.

--------------------------------------------------------------------------------

Causes of Fatigue

Fatigue, or "excessive daytime sleepiness", may be due to a variety of factors. These may exist singly or in combination and includes:
■Too little sleep
■Fragmented sleep
■Circadian rhythm disruption (such as occurs with night float work)
■Other conditions may masquerade as fatigue
■Primary sleep disorders

Too Little Sleep

This may be the most common reason for sleepiness among medical trainees, occurring when residents get less sleep than optimal. Although there is individual variation, most adults require an average of 8.2 hours of sleep each night. Residents may not have developed "good sleep habits" in high school, college and medical school for adequate sleep even on their nights "off".

Fragmented Sleep

Alternatively the duration of sleep may be optimal but the sleep itself is fragmented. Insufficient time may be spent in the "deeper, restorative" stages of sleep. Though "in bed", trainees may be interrupted by frequent phone calls, pages, the need to follow up on patients, or to supervise more junior trainees. Residents may also be interrupted by residents who share the same call space. Even the "anxiety" of call or anticipation of sleep interruption can impair sleep. Call from home, though not counted in the duty hours, may still put residents at risk due to sleep disruption with frequent phone calls or the drive back and forth to the hospital.

Circadian Rhythm Disruption

Residency training may disrupt natural circadian rhythm. This problem may be exacerbated as programs implement solutions, such as "night floats" to adhere to duty hour requirements. Night float systems and shifts may put residents on duty during periods in which there are predictable mismatches between circadian and endogenous rhythms of asleep and awake. Energy lows, for example, characteristically occur around 3-7 am and 3-5 pm. Residents may be more prone to errors during these times. It is extremely difficult to adapt to "shift work", regardless of how it is scheduled or its duration. Over 90% of individuals never adapt and may be at risk for sub-optimal performance. Working more nights in a row, rather than acclimatizing someone to night work, almost always only make someone more tired.

These rules are rotinely ignored.

There's a scene in the American tv series ER. Carter remarks forget about Superman. He calculates up the number of saved lives by Dr. Mark Green every day x his life and concluded that Superman has nothing on an ER doc.

Since we're 45,000 docs short, and 46,000 surgeons short, and there's no new medical schools, and we're adding millions to healthcare insurance, then will the problem get better or worse for those physicians and the poor RNs (who are in a 40 year shortage) who have to double check their work?

 

[El_Machinae]

It's a tough argument. The previous solution to the 'too much demand' problem was just to have millions of people who couldn't afford health care. I wonder if helping people get gps will help the ER load?

 

[Crackerbox]

We have an abundance of very intelligent diverse Millenials who could attend medical school and end up careing for our aging Baby Boomers as well as the younger generation. All we need to do is increase med school class sizes, hire more faculty, and commit to an action plan.

There are a ton of physicians who are retiring due to alterations in reimbursement and malpractice insurance costs. Why not recruit them to teach in these med schools as a stop gap to facilitate this?

I was just discussing the decline of African-American graduate students in med school. In addition many Asian-Americans cannot get in the way it is currently configured despite stellar GPAs and MCAT scores.

Why not have outright scholarships within med school tied to performance? The best and brightest would attend at no cost upon passing. That means they don't have the 250-500K of debt and so they don't have as big a need for income when first beginning. This is ridiculously simple and a great investment. Most students stop after the Bachelor's and then earn income. For a med student, there is a minimum of seven additional years without income. If that went away, then a major burden would be off their back.

If we've been in a RN shortage since the seventies, then maybe it might behoove us to steer young people into that career field as it pays very well, has good benefits and we could literally use every single soul who would be willing to do a two, three, or four year program.

Without doing this, it will NOT just help to give people insurance. This is a totally solveable problem if we will simply stop thinking that we can only fill the existing ceiling for med school. If we continue to think we can steal RNs from other countries, that won't solve the long term solution of creating an adequate labor pool in the USA.

 

[Timsup2nothin]

If the solution is more doctors the problem may not be worth solving, given that just keeping the current doctors busy has required turning 48% of the population into patients. Or are we saying that 48% of the population is genuinely in need of medical treatment?

 

[Crackerbox]

If the solution is more doctors the problem may not be worth solving, given that just keeping the current doctors busy has required turning 48% of the population into patients. Or are we saying that 48% of the population is genuinely in need of medical treatment?

Are you kidding? 100% of the population is genuinely in need of medical treatment. Why? Because they don't take care of themselves! They think that a pill will fix a persistent problem when maybe that problem needs addressing. The symptoms are not the problem, but the underlying cause of the symptoms is the problem.

Medical Adherence is a terribly neglected issue in America. 3/4 of Americans do NOT take their medication as prescribed!
http://www.scriptyourfuture.org/wp-content/uploads/2011/05/Final-FAQ-for-About-Page.pdf

Many of them could forgo their prescription IF they would fix underlying issues. Americans intuit that, and then self-medicate based upon when they decide to take it. They think, "Well, I'm feeling fine. I guess I'm better." then stop taking it. In reality, they might be able to stop taking their medications by tapering, but only under a doctor's care, for the way the drug is taken requires a build-up to the proper therapeutic levels to maintain a balance of the drug within their system.

Lose the extra 30-100 lbs you weigh, and maybe your heart won't have to pump so hard!

Do all Americans need constant medical care? Nope. There are statistical periods in which many young Americans won't need constant care and with only a small chance of accidents caused (mostly by risky behavior).

If all Americans had a routine and THOROUGH physical with screenings then we could catch a whole lot of underlying conditions before they got worse. But doctors are so hammered by patient load and minimal amount of time to see them, that this is all but impossible.

Americans are lucky that we have 209,000 family practice physicians, but many of them are located in the urban areas by necessity due to population density. We have 319 million Americans and we are not a healthy people as we once were. Watch some old films that then have been converted to youtube videos and you'll readily note the leaness of them collectively.

Let's say you're newly relocated to an urban area. Try getting a physician, and you'll probably encounter, "I'm sorry, Dr. ____ isn't taking new patients." Many are full and know that based upon need, that they can't reasonably care for them particularly if they have preexisting conditions.

 

[Timsup2nothin]

100% of the population is genuinely in need of medical treatment.

This is the false marketing that has led us into our current problem.

 

[Farm Boy]

Well, poor people don't need it fer sher Tim. I'm sure they'll be happier and healthier without the excess.

 

[Timsup2nothin]

Well, poor people don't need it fer sher Tim. I'm sure they'll be happier and healthier without the excess.

Poor people need one when they are genuinely sick...unfortunately when they are genuinely sick they can't afford to enter a marketplace dominated by insured people who have a tummy ache or a runny nose and a willingness to provide their doctor with a cash cow. That can't be fixed by increasing supply, as it is a demand side problem.

 

[Crackerbox]

The healthier a population, the less need a population has for physicians. Since physicians are at the top of medical care (due to the time to acquire a degree), then we could certainly accomplish many simpler care with physician's assistants and nurse practioners.

But we're not health. A doctor cannot magically make a populace healthy by existing. The patients must do the hard work of preventative maintence.

What would happen if you didn't rotate your tires, change your oil, fill up your radiator and properly mix the antifreeze? What if you didn't replace the tail light and head light bulbs in your vehicle? What if you continued to drive even though your windshield was cracked? Would you be okay for awhile without incident? Sure. But if something else happens, then suddenly you're stuck with a very expensive bill, accident, or worse.
http://www.huffingtonpost.com/2013/01/17/common-reasons-see-a-doctor-skin-disease_n_2497424.html

Spoiler :

They found that the top 10 most common reasons for seeing the doctor were:

1. Skin disorders, including cysts, acne and dermatitis.
2. Joint disorders, including osteoarthritis.
3. Back problems.
4. Cholesterol problems.
5. Upper respiratory conditions.
6. Anxiety, bipolar disorder and depression.
7. Chronic neurologic disorders.
8. High blood pressure.
9. Headaches and migraines.
10. Diabetes.

These are the top 10 reasons for seeing a physician, but realize that by that late period in which the patient comes in, they have multiple things going on that manifest as symptoms.

Back problems are caused by being overweight and forcing the natural curves of the spine to be out of alignment, causes grinding upon the vertebrae and discs such as to cause wear. People are dehydrated and so that disc then is smaller and thinner. That means that grinding causes pain. Once you go down this route than people will not alter their lifestyle but manage it with drugs. Of course, that won't fix the problem at all! Joint disorders might be osteoarthritis or rhemumatoid, but most are caused by being obsese or abusing the body by repetative stress leading to longer term issues like knee replacement.

Multiple disorders like anxiety and depression are caused by poor self-image due to being overweight, marital or relationship issues, job insecurity or lack of satisfaction, the passage of time and milestones, grief, etc.

Diabetes is a long term management disorder in which multiple systems get involved with eventual uncontrolled blood sugar leading to circulatory issues, amputation, and blindness.

The bulk of cholesterol problems can be handled by proper diet, and yet we know that in children aged 6+ in America, they already are forming plaque within their blood vessels. Why? Too much red meat and fat in the diet.

A cheap Japanese scrubbing cloth buffs the skin versus a wash cloth, exfoliates, removed small clogged pores with bacteria within, and so reduces the outbreak and then results in a form of body massage that induces well being. Many skin ailments could be eliminated by merely doing this short preventative maintenance item into your shower/bath time.

Many upper respiratory issues could have been treated by using clean boiled (and then cooled) water with salt added into a netipot to do a nasal rinse. As bacteria naturally will take up shop there, then when the fragile passages are broken, it's easy to get a viral or bacterial infection. It's just that Americans are not used to using a netipot.

Link to video.
http://www.webmd.com/allergies/sinus-pain-pressure-11/neti-pots
The only risk is if you do not boil it or add the salt to prevent introducing microrganisms into the nasal passages.

The bulk of the top 10 health issues could be VASTLY reduced by patients doing preventative care. Take a walk. Talk to your spouse instead of yelling or ignoring them. Plan a healthy family meal and talk to your children. Carefully wash up every single day. Eat right and in moderation and take a vitamin if you don't do this.

Perhaps 85% of routine family practice calls could be eliminated.

 

[Timsup2nothin]

Perhaps 85% of routine family practice calls could be eliminated.

And doctors are the front line of defense against this becoming common knowledge, because their lifestyle is built on "come see me and I'll bill your insurance" rather than on actually providing any significant service.

 

[Farm Boy]

Tim, if you get out into the boonies they've been staffing accessible medical offices with nurses instead of MDs. You gotta have something more wrong before you get a doctor. From my experience, you're overstating. Again, maybe the urban West is particularly stupid with criminality for ethics , but I don't want to default into that assumption.

 

[Timsup2nothin]

Tim, if you get out into the boonies they've been staffing accessible medical offices with nurses instead of MDs. You gotta have something more wrong before you get a doctor. From my experience, you're overstating. Again, maybe the urban West is particularly stupid, but I don't want to default into that assumption.

How do you get a doctor to go work with sick people in the boonies when they can become a podiatrist, live in the city, and bill $400 an hour for trimming toenails?

Like I said, it is a demand side problem and increasing supply is not the answer.

 

[dutchfire]

Or are we saying that 48% of the population is genuinely in need of medical treatment?

I actually agree with Crackerbox here, many (most) of us could use some medical care. Not surgery, but someone who has a look at our diet, someone who makes sure our desks are ergonomically okay and perhaps a psychologist now and then. There are still many quality-of-life-adjusted years to be won there.
But it probably doesn't pay as well as surgery.

edit: And regular dental check-ups of course...

 

[Farm Boy]

Unless you're actually short on supply. But ok, you've convinced me. People out there suck donkey balls. It's great that I'm forced to share the country with the rich pricks. Yayyyy, city people! May the carcinogens of your chosen environments accumulate. Handgun violence isn't a scourge, it's a winnowing.

 

[Crackerbox]

How do you get a doctor to go work with sick people in the boonies when they can become a podiatrist, live in the city, and bill $400 an hour for trimming toenails?

Like I said, it is a demand side problem and increasing supply is not the answer.

Why don't you try shadowing a physician for one day, and then reporting back? You have some odd ideas about physicians in general.

The things I mentioned are COMMON SENSE. A physician cannot make patients take care of themselves. It's about personal responsibility.

 

[Timsup2nothin]

Why don't you try shadowing a physician for one day, and then reporting back? You have some odd ideas about physicians in general.

The things I mentioned are COMMON SENSE. A physician cannot make patients take care of themselves. It's about personal responsibility.

That would be a demand side solution, and would contribute to solving the problem. Unfortunately for doctors it would have an adverse affect on their incomes. Unfortunately for the rest of us, doctors have no intention of letting that happen...and have the collective marketing power to prevent it.

@Dutchfire...while many people "could use some" economics says that it doesn't come without opportunity costs. Insurance, insurance provided in place of direct compensation in the workplace, insurance provided by the state...these are all methods for disguising the opportunity cost and getting doctors paid for services that their customers would likely not pay for otherwise.

The kid has the sniffles. Yeah, he may have ebola, but he by far most likely has the rhinovirus. You have a couple hundred bucks in your wallet for discretionary spending this week. Some peace of mind is available in the form of a well educated guy who for most of your cash will confirm that it is indeed the common cold and nothing to worry about. Is that how you spend your money? But you never actually make that decision, because you only recognize the five dollar copay as the cost of your peace of mind.

 

[Farm Boy]

Five dollar copay? I work a full time job with poor cash compensation only for the health insurance. My copay, for a lot more than five dollars, for notably more than five dollars in transportation, and probably also demanding time off that full time job, gets me an RN that either says, you're fine, or, here's some antibiotics, or, go to the ER. The ER costs a two hundred and fifty copay and is for a longer and larger transportation expense the only real option available outside of standard work hours. If something is well and truly terrible wrong, depending on which ambulance district you live in, it can be a matter of life and death to know whether you should dial and wait for the ambulance or if you should dial and inform the cops you are about to be speeding on a certain road and would like to be met by an ambulance. Big city problems, eh Tim?

 

[Timsup2nothin]

Big city problems, eh Tim?

Well, possibly just antiquated references. My kids are all in their thirties after all. But while the specific numbers may not be current the argument remains the same. The decision based on opportunity costs is skewed by disguising those costs through prepayment.

 

[Crackerbox]

If you have the sniffles, then wouldn't it behoove you to use a neti pot twice a week and flush out viruses and bacteria? If it's hay fever season and there is an abundance of pollen in their air, then would swishing out the pollen be a good idea? A neti pot costs less the ten dollars. Salt and boiled water are pretty cheap.

Compare that with even one visit to the physician. If it's a cold, then there is no cure. If it's bacterial, then you'll have a higher fever and yellowish-greenish drainage. Then antibiotics are needed. If your fever is low and clear drainage, then it's viral and there really isn't anthing but an antiviral to lessen the severity of symptoms.

Both could be taked care of by routine health maintence, but you want to blame the physician for getting payment. I wonder, do you blame a carpenter when something needs repairing in your home? What about a plumber when you failed to have maintenance on your septic tank or put the wrong garbage down the drain?

Weird, Tim.

So maybe 85-90% of the time, that case of sniffles requires no medication. A physician wasn't needed. Do you know why people get bacterial infections? They swallow their phlegm. As they do this, instead of coughing it up or using a tissue, then it flows down the throat and picks up food particles. The cilia sweep it back up the throat, and the drainage now has all manner of bacteria in it. That's the primary mechanism for bacterial infections and is pert near preventable.

Link to video.
Do you know what percussive therapy is? Since we have a lot of cystic fibrosis patients, they have phlegm that catches in the narrow bronchi of their lungs. But this can be done on any patient who has thicker mucus in their lungs.

When a person coughs, a majority of the time it is to clear the narrow passage so blocked with phlegm. As such, you can prevent this from happening, cause the mucus plug to be expelled, and costs NOTHING. All parents could do this. All spouses and lovers could do this. If they did, then an expensive breathing treatment and oxygen would be less necessary in routine cases.