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Entries in Clinical Medicine (23)


The Shadowy Price Fixing World Of The AMA & RUC

Want to know how the AMA controls prices for healt care in the US?

The RUC (of the AMA) meets in secret to divvy up roughly $85 billion in U.S. taxpayer money every year. And that’s just the start of it. Because of the way the system is set up, the values the RUC comes up with wind up shaping the very structure of the U.S. health care sector, creating the perverse financial incentives that dictate how U.S. doctors behave, and affecting the annual expenditure of nearly one-fifth of the United State's GDP.

From this article from Washington Monthly

While these doctors always discuss the “value” of each procedure in terms of the amount of time, work, and overhead required of them to perform it, the implication of that “value” is not lost on anyone in the room: they are, essentially, haggling over what their own salaries should be. “No one ever says the word ‘price,’ ” a doctor on the committee told me after the April meeting. “But yeah, everyone knows we’re talking about money.”

That doctor spoke to me on condition of anonymity in part because all the committee members, as well as more than a hundred or so of their advisers and consultants, are required before each meeting to sign what was described to me as a “draconian” nondisclosure agreement. They are not allowed to talk about the specifics of what is discussed, and they are not allowed to remove any of the literature handed out behind those double doors. Neither the minutes nor the surveys they use to arrive at their decisions are ever published, and the meetings, which last about five days each time, are always closed to both the public and the press. After that meeting in April, there was not so much as a single headline, not in any major newspaper, not even on the wonkiest of the TV shows, announcing that it had taken place at all.

In a free market society, there’s a name for this kind of thing—for when a roomful of professionals from the same trade meet behind closed doors to agree on how much their services should be worth. It’s called price-fixing. And in any other industry, it’s illegal—grounds for a federal investigation into antitrust abuse, at the least.

Via this post on Medical Spa MD


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Hello Doctor. I Wouldn't Hesitate To Sue You

nonclinical medical malpracticeGuest post by Dr. Mandy Huggins

How many times during your day does the specter of a malpractice law suite rear its ugly head?

“I wouldn’t hesitate to sue you.”

"I’m sorry, what?"

That is what I heard from the mother of one of my patients. At the time, I was only 2-3 months into practice, and I was evaluating a high school athlete who had recurrent stingers and a possible episode of transient quadriparesis . I wasn’t on the sidelines for these injuries, so I had to go on the reports given to me by the athlete and the school’s athletic trainer. However, with that information, I did not want to clear this player to return to football until I could be certain he didn’t have cervical stenosis or any other abnormality that might put him at risk for permanent damage if he suffered another neck injury. I told the athlete and his mother that I needed to get an MRI of his cervical spine in order to determine this. The athlete was understandably upset with my decision, but his mother supported my decision to proceed with caution. She explained to me that if her son played again, sustained another injury, and something “bad” happened, she would be more than happy to take legal action against me.


First of all, I can’t say that I would blame her for being angry (at the very least) if I screwed up. But to tell me in my office, to my face, that she’s already thinking about suing me? I found that ridiculous. I must be in the minority, however. If you Google “how to sue a doctor,” an abundance of information follows. There’s an “ehow” on the subject, and even CNN offers an opinion.

I’m sure many can offer some anecdote about how a physician did this or that wrong, and I agree that there are some bad apples out there. That’s not the point of this post. The point is, way too many people are looking, just waiting, for something to happen to they can “get theirs.” It’s disappointing, and quite frankly, very scary. I didn’t go through a lifetime of education and training to doubt everything I do for fear of a law suit. I’m lucky; my specialty is non-surgical and rarely deals with critical health issues. But I’m hardly in the clear. A 2011 study in the New England Journal of Medicine estimated that by the age of 65, “75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties.” So I have a 75% chance, give or take, that I’ll be named in at least one claim during my career. Of course, not all of these claims go to court and/or end up with the plaintiff being awarded, but you can see how frequently patients are quick to take action if they think they’ve been wronged.

I’ll continue to do what I’ve been trained to do – practice good, evidence-based medicine, communicate well with my patients, and document the you-know-what out of everything. But at the end of the day, the fear of a malpractice claim, valid or not, will always be in the back of my mind.

About: Dr. Mandy Huggins, MD is a sports medicine physician who practices in south Florida. She is board certified by the ABPMR and holds an added certificate of qualification (CAQ) in Sports Medicine. Learn more about Dr. Huggins at

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The Pharma Rep Physician Hunting Guide

Ah the famous charts and smiles crowd. Hat tip to ZDoggMD.


Emergency Medicine + Perception Problems

I was thinking this week about how Emergency Medicine physicians are perceived in busy Emergency Departments.

For those of you who aren't medical people or don't work in Emergency Medicine, a busy ER is a crazy place.  There is a constant push to make every action more efficient.  Patients are being taken to and discharged from rooms as quickly as possible so the ill in the waiting room can be evaluated.  Activities that aren't completely necessary are eliminated, simply because of the crush of needy people waiting for care.  

There is a mountain of medical literature discussing the issue of ER overcrowding, and a current focus on training physicians to eliminate any testing that isn't absolutely required.  Twenty years ago physicians working in ERs did full work ups on patients.  Today, the focus is on singling out that handful of tests that will give the physician a clear picture of the patient's pathology, so a decision can be made as soon as possible and the patient moved into the hospital or discharged home.  

Now, insert into this chaos two physicians, we'll call them Dr. Flippant and Dr. Effective (for the sake of comparing two styles and nothing more, let's make these physicians both male).

Dr. Flippant walks into a patient room having barely reviewed the chart.  He interacts with the patient in a superficial way, barely asking questions because he really isn't interested.  He does a cursory physical exam, orders no tests, and sends the patient home.  His total time in the patient's room is under three minutes, after the patient waited hours to see him. 

Now let's look at Dr. Effective.

Dr. Effective walks into a patient room having thoroughly reviewed the patient's data.  Because his ER is so busy, he begins his patient assessment the moment he enters the room, guaging the patient for unlabored breathing, ability to move in a symmetric and balanced way, and appropriate responses to questions.  He notes the color of the patient's eyes and skin, the smell of the room, and whether the patient is perspiring.  All these things are taken in within the first few moments of the physician-patient interaction.  Dr. Effective asks a few questions that are targeted, and purposely phrased to limit long responses but give maximum data for his decision making.  He does a focused physical exam, limiting the exam to the body part or parts that will quickly allow him to determine if this patient needs further testing.  Once complete, his very targeted-- yet appropriate and effective-- assessment has determined that the patient needs no further testing, and he sends the patient home.  His total time in the patient's room is under three minutes, after the patient waited hours to see him.

Now here's the problem with the perception of these two physicians...

In each case above, the time constraints limited these two physicians to less than three minutes with their patients.  However, one of these examples was a flippant, sloppy physician and the other was an effective and appropriate physician.  

The difficulty is that if you're the patient in the room, it's almost impossible to ascertain which example is treating you.  Both spent little time at your bedside.  Both asked few questions.  Both did limited exams, and neither ordered any tests.

Now, if you couple this with the confounding variable that Dr. Flippant is a charming, visually appealing person, and Dr. Effective has a more curt personality and frumpy look, the perception issue becomes even more difficult.

To the untrained eye, these physicians did the exact same thing with both their patients.  The difference between these physicians was the processing that was going on internally.

Even an excellent physician-- working efficiently and effectively taking care of a large number of patients-- in a busy ER  frequently gets feedback from patients and families that he "didn't spend time with me" or he "wasn't interested in my problem" or he "didn't even order any tests." It is difficult to explain to these idividuals that the physician was actually acting appropriately, when the patient is incensed that after their long wait time "that's all the doctor did."

What's worse, if you're the patient, you have really no way of determing which doctor took care of you.  How can you be assured that you saw Dr. Effective and not Dr. Flippant?  The unfortunate thing is that unless you have medical training or a medical family member interacting with the physician, it's almost impossible.

In my view, this is one of the most difficult issues in contemporary Emergency Medicine-- the very subjective and often skewed perception issue.  It's unfortunate, and it's a big problem for patients, and for the good physicans out there trying to take care of them.



The Medtrix

What is The Medtrix? It is the medical career that has been pulled over your eyes to blind you from the truth: that you are a slave.

Look, I've come to terms with the fact that I'm a massive nerd. I can only parse the world through the lens of science fiction movies I've seen. Don't laugh now—it's a real condition with its own ICD-9 code: 003.14, Dorkiness NOS. The typical signs and symptoms include choosing Internal Medicine as a career, owning 20-sided dice, and receiving unexpected wedgies at cocktail parties from orthopods named Chip.

But after working as a full-time clinical hospitalist for almost 9 years now, I'm starting to appreciate some eerie parallels to the sci-fi classic The Matrix. Although I admit I have yet to see a single doctor at the hospital wearing a skin-tight leather bodysuit. Scrub-chaps, maybe, but no leather. Wait, where was I?

Oh yeah. For many of us practicing clinical medicine, the world can sometimes take on an unreal, dreamlike quality. Like we're going through the motions of someone else's life.

Have you ever had a dream, Neo, that you were so sure was real? What if you were unable to wake from that dream?

For the majority of my clinical career, I've had this nagging feeling. I'm suspecting many in medicine today may have felt similarly: that the REAL world is out there, and we're trudging through someone else's construct instead. The key question we have to ask ourselves is less HOW to escape the Medtrix, but WHETHER to escape.

You have to understand, most of these people are not ready to be unplugged. And many of them are so inured, so hopelessly dependent on the system, that they will fight to protect it.

Take the blue pill, continue along your current path. Take the red pill, and see what fascinating opportunities await you outside of, or in addition to, the confines of clinical medicine. One thing though: avoid the brown pill. Trust me on this.

Over the next few weeks and months I'd like to drag you through my own journey from pure clinician to…well, like any good sci-fi series you'll have to stay tuned to see what happens! Hang tight and together we'll see how deep the rabbit hole goes.

You have to let it all go, Neo. Fear, doubt, and disbelief. Free your mind. Welcome to the real world.



Patients Who Bill Their Doctors For Being Late

Meet Elaine.

We lost touch for a while, but caught up with each other recently.

Like most girlfriends, we shared adventures of love, travel, and work. I told Elaine that I left assembly-line medicine. Now I host town hall meetings-inspiring citizens nationwide to design ideal clinics and hospitals.

Elaine shared: ”If I’m kept waiting, I bill the doctor. At the twenty minute mark, I politely tell the receptionist that the doctor has missed my appointment and, at the thirty minute mark, I will start billing at $47/hour.”

Wow! I had to hear more.

Elaine scheduled her physical as the first appointment slot of the day. She waited thirty-five minutes in a paper gown before getting dressed, retrieving her copay, and informing the receptionist to expect a bill. The doctor pulled up just as Elaine was leaving.

Prior to her initial visit, Elaine signed the standard agreement outlining no-show and late fees. On follow up, Elaine knocked on the door and discovered her therapist with another client. He apologized for his scheduling error. Elaine sent a bill; check arrived the following week.

Elaine values herself and her time.

When the Comcast guy told her to wait at home between 3:00-6:00 pm, she said, “Expect a $141.00 bill. Is that okay with your boss?” A compromise: The driver agreed to call fifteen minutes ahead of arrival.

I was intrigued. Who pays for waiting?

Cab drivers charge hourly for waiting. Restaurants may provide a discounted meal for the inconvenience. Airlines cover hotel rooms for undue delays. Some physicians apologize. I offer a gift.

Central to medicine is a sacred covenant built on mutual trust, respect, and integrity. What happens when physicians fall into self-interest or self-pity? Or when physicians are so emotionally, physically or financially distraught by their profession?

Patients suffer. And their wait times increase.

So what’s a doc to do?

  1. Remember: Respect is reciprocal. If physicians are on time, patients will be on time. If physicians don’t cancel appointments with little notice, patients won’t either. Doctors should stop charging fees they are unwilling to pay themselves.
  2. Functional clinics attract functional patients. Patients fall to the level of dysfuntion within a clinic. A chaotic, disorganized clinic attracts chaotic, disorganized patients. Take care of yourself; uphold high standards and healthy boundaries.
  3. Don’t wait. Doctors should apologize for delays. And if presented with an invoice for excessive waiting, doctors should gladly pay the fee. Fortunately, most patients don’t bill at the doctor’s hourly rate.

My opinion. Share yours:

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