Swap “Doctor” for “Teacher”

Bradley Flansbaum

Posted 2/25/12 on the Hospitalist Leader

If you have not heard, the NYC Dept. of Education released a report card assessing all of its 18,000 teachers.  It is making a lot of noise, particularly here in the city.  Read the story, regardless of where you live–it is interesting and a policy exercise that is no doubt, coming to a theater near you.

What is striking, and I allude to it in my title, is the resemblance of the arguments here, as compared to those made by the physician community.  The CMS ratings site will ramp up with substantive data in the upcoming decade, and the same fears of inadequate adjustment, sample size, and inaccurate information are front and center:

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We All Must Die Sometime. We Just Don’t See It

Bradley Flansbaum

Posted 2/19/12 on the Hospitalist Leader

There was an exceptionally well-written piece published in the Washington Post this weekend. I presume a hospitalist wrote it, which magnifies its significance. In it, he describes the difficulties in caring for terminally ill patients.

As I read it, it reminded me of a story my dad told me several years ago. His friend, I will call him Steve, was experiencing a great deal of stress because of his dad’s ailing health. You see, his father had end stage dementia.

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Green House-ists

Bradley Flansbaum

Posted 11/06/11 on The Hospitalist Leader

The August study in The Annals of Internal Medicine assessing global costs of hospitalist care both inside the hospital, and subsequent to discharge initiated reflections within our ranks.  It was also prominent in the lay press (“Are hospital-based doctors fueling health spending?“).

I found the data credible, and the conclusions that questioned our efficiency authentic.

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Readmissions Revisited…Again. With New & Improved Data!

Bradley Flansbaum

Posted 10/19/11 on The Hospitalist Leader

Two important review papers are out this week (state of the art) and deserve mention in the blog.  They both dovetail nicely, and serve as bookends in our approach to readmission management.

One examines RISK of patient readmission, and the other reports INTERVENTIONS to prevent it.  Unfortunately, the literature falls short on both counts.

Assessing discharge recidivism rates is dicey at best, and given the state of evidence, again, we are called upon to correct a systemic problem—one with multiple causes—with unsatisfactory tools.  This frustrates not just hospitalists, but the health system at large given the uneven progress in improving this metric.

If we cannot predict who will return to the hospital, or choose proper interventions, performance ranking and penalties are premature.  A recurring theme, the same concern exists with standardized mortality ratios (SMR).  Moreover, if there is any doubt as to assessments in that realm, this citation is sobering.  The horse has left the barn however; we are stuck, and resistance is futile.

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GME – Part II

Bradley Flansbaum

Posted 10/16/11 on The Hospitalist Leader

My last post discussed the dollars allocated to GME funding, and the constituents involved in defending it.  The American Association of Medical Colleges (AAMC), AHA, and academic medical centers all are proponents of continued support.  Members of congress representing districts with training hospitals also endorse sustained flows of tax dollars into to these facilities for obvious reasons.

Below is a frequently distributed graph illustrating the actual and theoretical demands for future physician labor:

Given this shortfall in staff then, why would the government cut funding?

We work in hospitals and it is natural to safeguard services that are essential by our standards.  However, front line physicians have not mastered the actuarial sciences, and our assumptions regarding what is “vital” differs.  My objective however, is not to promote the projections of others—right or wrong, but alert you to alternate views so you may formulate a reasoned stance.

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Experience is not the Answer

Bradley Flansbaum

First posted 8/25/11 on The Hospitalist Leader

I assume, incorrectly perhaps, that mechanics have a basic knowledge of their craft such that routine auto repairs require little effort.  The tasks do not supersede the expected competency of the repairperson, and the customer can expect a car that operates at the time of pick up.  A small percentage of jobs may stretch that assumption, but that is okay by me.  Just like medicine, some mends are complicated. You need assistance from another mechanic or you refer the auto to a specialty garage.  No one is superman.

How does this relate to the practice of medicine?

I frequently notice pharmaceutical ads on Sunday AM television broadcasts, as well as newspaper articles that advertise a medical product, or report on a new device, surgery, or therapy—usually of the latest and greatest vintage.  As the data for these interventions is incomplete, or the costs unknown, the story concludes with a riposte conveying that the reader need not concern themselves with the alien facts—just “consult your health professional” and all will be well.

I also observe that politicians object to “meddling” when EBM-based policies from expert committees passively (or actively) affect the doctor-patient relationship, especially as it relates to decision-making and the counsel we provide.  Just watch the nightly news—sound bites abound.  This relationship is sacrosanct after all, and our advice is authoritative and 98.7% correct.  Who would question a physician after all?

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