1) Dartmouth Medical School is leading the “slow medicine” movement, where the elderly are given the decision whether to pursue more intensive medical therapies.

My take: Bravo. This trend needs to be publicized and spread nationwide. Much of Medicare’s spiraling costs can be attributed to unnecessary end-of-life care.

We need to communicate the acceptability of saying “no”, and give patients more of a say in the treatments they undergo.

2) The RUC is responsible for coming up with a payment mechanism for the medical home.

My take: Specialists continue to hold primary care by the balls.

The RUC is dominated by specialists and sub-specialists. Until this committee is completely disbanded and reformed with a generalist majority, primary care will continue to get the payment shaft.

Go and read The Happy Hospitalist’s detailed analysis for how the RUC is sinking the proposed medical home.

3) A reader writes: “Have you seen any hospitals that are able to avoid the bantering and animosity between the ED docs and the admitting docs over admissions?”

My take: I’ve seen both. There are cases where hospitalists are happy to take every admission, and others where there is considerable resistance.

It comes down to the degree and acceptance of defensive medicine practiced within the hospitals. Just as hospitalists occasionally order questionable tests defensively, emergency physicians admit borderline cases on cya basis.

Physicians with an understanding and acceptance of what’s really going on generally avoid the animosity that is associated with questionable admissions.

4) A reader writes: “Curious as to where physicians see the dividing line between ‘patient relations’ and ‘risk management’. At what point does a patient who has a legitimate concern he’d like to discuss stop deserving communication and start having to be treated as a potential lawsuit — never mind that the patient has shown no sign of being interested in suing?”

My take: Patient relations and risk management go hand in hand. Studies have shown that better communication can reduce the risk of malpractice lawsuits.

Unless the patient actually sues, there should be no barrier obstructing patient communication with the physician. Sadly, this is rarely the case, as I wrote in a recent op-ed.