Monday, January 23, 2012

Is there a doctor on the plane? Better check his ID.

So here I sit, delayed, en route again to Las Vegas.  On my last trip out there I was awakened by the call that all medical students secretly crave, and all physicians loathe... "Is there a doctor on the plane?"

Grabbing my shoes in my right hand and bounding towards the front I arrived to find out what was going on.  It turns out a youngish gentleman had falled to one knee and potentially passed out while attempting to go to the bathroom.  By the time I arrived he was awake and seated and looked only a little worse for the wear.  A quick conversation with him and his friend indicated the likely cause-- an 80 degree airplane (couldn't they open a window?) and an afternoon of drinking had left him fairly dry, and he suffered a bit of the old vasovagal syncope.  With the assistance of another passenger, a nurse, I was able to barely obtain vitals with the loud plane and the small stethoscope.

The three flight attendants were variably helpful, one accurately reading the situation and supplying the water & juice, ice packs and vomit bag that I requested.  A second was insistent that oxygen would help, and so I obliged.  But the third...  the third one was there to do the paperwork.  It looks like healthcare is the same everywhere.  Thankfully she wrote most of what I was saying down so I didn't have to write a visit note myself (As though I were submitting a bill).

Things got very interesting when I asked what was in the medkit. I observed a small back pack size kit that was "very well-equipped" but no one could accurate describe the contents.  I asked if we could open the kit so I could familiarize myself with the tools.  Not that our patient needed any more services than we were currently providing, but I have learned to know my tools and plan ahead.  I was told repeatedly that unless I knew what I wanted out of the kit (impossible as I did not know the contents), that they did not want to open it because they would have to call it in and fill out yet more paperwork.  Understandable I guess, but who decided to set the paperwork bar so damn high?  Had the gentleman been sicker am I really supposed to negotiate with someone at 30,000 feet about how much paperwork they have to do?

Fortunately our patient did well and no drastic decisions were required.  At the conclusion of the who situation I received a brief thanks from the staff, and then it happened.  "Um, Doctor... can we have a copy of your medical license?"

AFTER?!?!  Barely a thank you, not to mention the free drink or upgrade my family or friends insist I rightfully deserve, (I am not so naive...), but after I have rendered a service and made a medical decision, that is your chief concern, to make sure I am not faking?

I am sure the on board medical emergency policy was decided upon by very intelligent folks with a great background, not at 30,000 feet, but from an airline that prides itself on service (and usually delivers), I felt that the entire situation was odd a best and stinking of litigation fear at worst.

I am flying again tonight, and if called I will be there.  But I really hope I can sleep on my now delayed flight to Las Vegas.

Latest from the SGIM Forum: “It’s not What You Earn but What You Keep That Counts"

My latest publication in the Society of General Internal Medicine Forum, about the mystery of doctors being both overpaid and underpaid.  I'd like to thank my mother-in-law, Iris Stern, for sending me the article that was the inspiration for this piece.

Cost of Care Essay Winners

The folks at Costs of Care have started posting the winning essay.  The first is by Renee Lux, a patient who underwent a CT scan "just in case" and found herself uninsurable!  It is a chilling description of just how distanced the clinical and the underwriting have become in modern health insurance.

Thursday, January 19, 2012

Speaking of ICUs... Check out the Intensive Code Unit

Check out the Intensive Code Unit, the ongoing masterpiece of our technical team at Iora Health.

My first panel

Last night I had the honor of serving on my very first panel on Primary Care Innovation at Harvard Medical School.  Arranged by the Center for Primary Care @ HMS and Primary Care Progress, I had the pleasure of sitting with luminaries Soma Stout, Asaf Bitton and David Judge and share our work in Primary Care innovation with a group of enthusiastic medical students.  There apparently was a video, and I proposed to the others that we take our show on the road.

One of the questions that came up was how to square ideologic differences between each of us with our work in primary care.  We were asked which was more important, maximum equity, maximum efficiency, etc.  I think we all chuckled as we recognize that right now all we have is maximum waste!  I actual look forward to a future when all of us working hard to reinvent primary care and all health care can bicker as old men and women about the exact ideal direction to go.  Until then, we keep solving one problem at a time, moving forward.

To the students out there who are interested, we at Iora Health are looking for a medical student to join us for (at least) the summer, and perhaps a resident intermittently throughout the year to help with some of our exciting work.  If you are interested, please e-mail me.

Cost of Care Essay

It has been a wild ride since I entered the Costs of Care Essay competition.  The Boston Globe reported on it here (with a nice promo for the Schutzblog).  Here is the essay in full:


“$1400 a day!”
Cost of Care Essay Contest Submission
Andrew Schutzbank MD, MPH

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension.  So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open.  Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension.  Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours.  Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision.  As you can imagine, this drug was mighty expensive.  We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs.  Once stabilized, our first challenge was to ensure that she continued on the treprostinil.  It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress.  Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab.  But her progress was stalled for one simple reason: treprostinil. 

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her.  As it turns out, treprostinil costs $1400 per day.  $1400.  Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state.  But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized.  Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment.  A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home.  Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil).  But we are doctors, not financial engineers.  We work in the world of medicines and were unable to orchestrate such an unusual arrangement.  So we did the only thing we know how to do.  We stopped the expensive medicine.
This was not a financial decision.  Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines.  Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense.   We monitored her closely during the transition and she quickly improved!  She was able to move around more and started on recovery.  She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one.  But ironically, we would not have considered it if were not for the cost factor of the medicine.  Peggy would have gone on for some time on an expensive medicine that was not helping her.  At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied.  The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day.  Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time.