Specialists writing on KevinMD about their practices: what private equity does when it buys a specialty group, from dermatology roll-ups to staffing companies, and whether nurse practitioners and physician assistants belong in every specialty and on what terms. Two maintained records draw on this archive: Private equity and corporate medicine: what physicians say, in their own words and Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words.

The challenge of pre-authorization for an elective procedure

Health Policy
June 27, 2011

by Grayson Wheatley, MD

It was supposed to be a routine office visit for my patient.

Unexpectedly, it turned into a real-world health economics lesson for me, the treating physician. The old adage “listen to your patients; they will always give you the answer” became exceedingly true in this case, even when it dealt with an issue beyond a medical diagnosis, such as lack of transparency …

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The challenge of pre-authorization for an elective procedure

Differences between obstructive and central sleep apnea

Conditions and Diseases
June 26, 2011

In sleep disorders, obstructive sleep apnea is the most common condition that’s seen, but a significant number of people with obstructive sleep apnea will also have central sleep apnea.

Central sleep apnea is thought to be a condition that’s associated with a number of different neurologic problems, as well as heart or kidney failure. During the night, people with central sleep apnea stop breathing when signals in the brain that …

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Differences between obstructive and central sleep apnea

New fields in general surgery and the rise of the surgical hospitalist

Physician
June 24, 2011

As medicine adapts to the 21st century, new specialties arise.

General surgery is seeing two new fields emerge. One is “Acute Care Surgery,” which encompasses three facets of general surgery — emergency surgery, critical care and trauma care. The other is the concept of a surgical hospitalist. That is, a surgeon works only in a hospital and has no office or private practice. The idea is similar to the medical …

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New fields in general surgery and the rise of the surgical hospitalist

Resident responsibility at a Level 1 trauma center

Medical Education
June 23, 2011

Debates over resident autonomy are nothing new. Informed patients are sometimes reasonably concerned about just how much responsibility for their care will be delegated to their doctor’s trainees. Care within academic medicine, especially acute inpatient care in a public system, can and does sometimes mean going a whole admission without meeting the attending physician presumably responsible for your care as a patient. At least in my limited experience. This as …

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Resident responsibility at a Level 1 trauma center

Difficult testing decisions for parents with premature babies

Physician
June 22, 2011

Many people think that tests (blood work, x-rays, scans, etc.) mean their doctor is doing something constructive and working hard to figure out what is wrong. But tests are a double-edged sword.

When I trained most diagnoses were derived from careful history and a physical exam. Perhaps because our province did not have funds to have enough CT scanners and we didn’t have an MRI, those tests were on a …

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Difficult testing decisions for parents with premature babies

How physicians should deal with angry patients

Physician
June 21, 2011

I highly recommend you take a look at “10 Dumb things you do at the doc’s office.”  Be sure to scan the article, but what you really need to look at is the comments, all 700+ of them.

While by no means a representative sample of how we think about physicians, there is a clear pattern to the comments.  A lot of people feel disrespected by their doctors, …

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How physicians should deal with angry patients

Shifting procedural work to midlevel providers

Physician
June 21, 2011

It is entirely clear that too few medical graduates go into primary care.

Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements …

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Shifting procedural work to midlevel providers

Why the AMA is in decline, and should doctors care?

KevinMD
June 20, 2011

The American Medical Association recently released its membership numbers, and they’re declining.

According to MedPage Today, the AMA “saw another steep drop in its membership in 2010 — this time losing about 12,000 members or 5% of its total membership.”

It’s been well publicized that the AMA only represents a minority percentage of physicians, depending on what you read, it’s between 20 and 30%.  But it seems many physicians have little …

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Why the AMA is in decline, and should doctors care?

Doctor Kevorkian dead, but not by suicide

Physician
June 20, 2011

Recently it was announced that Dr. Jack Kevorkian (also known as Dr. Death) died — ironically, not by suicide.

As a psychiatrist, one of the things I consider part of my job description is suicide prevention.  Although many consider Dr. Kevorkian a civil rights activist for assisted suicide, I believe that there was a severe lack of ethics in his medical practice.

From everything I’ve read in the media (and I …

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Doctor Kevorkian dead, but not by suicide

What big hospitals can learn from smaller ones

Physician
June 17, 2011

Every now and then a tonsillectomy patient bleeds after arriving back on the ward after surgery.  On this occasion, there was nothing remarkable in the event itself.  What was remarkable was the efficiency of the response.

I got the phone call from the ward sister at 11:05 am, and immediately drove the short distance back to our local hospital.  I checked on my patient in the ward, confirmed the bleed, …

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What big hospitals can learn from smaller ones

Pro-actively improve quality, rather than reacting to liability concerns

Physician
June 16, 2011

Over the past year I have been involved in many discussions with doctors, healthcare executives, elected officials, plaintiff and defense attorneys and others about healthcare reform. Bottom line: There is no consensus what the future holds.

There is no question that reform is necessary to avoid absolutely bankrupting the country. However, the recent legislation is a work in progress, not yet an achievement. A change in congressional leadership could derail, …

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Pro-actively improve quality, rather than reacting to liability concerns

How switching from brand name drugs to generics is sometimes absurd

Medications
June 16, 2011

I had an interesting exchange with one of our nurses recently about a long-term patient of ours.

The e-mails went something like this:

Got a fax from —-’s insurance that his Lipitor won’t be covered anymore.  They will cover simvastatin, lovastatin, and pravastatin.  Let me know what you want to do.
Charlie

He’s on darunavir, and all three of those statins are contraindicated because of drug-drug interactions. Rosuvastatin?
Paul

Checked with them — rosuvastatin needs …

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How switching from brand name drugs to generics is sometimes absurd

We want our doctors to be perfect, but they’re human too

Physician
June 16, 2011

Though there are few subjects as immediate to my experience as that described in Gardiner Harris’s article in The New York Times, “More Doctors Say No to Endless Workdays,”  perhaps the truest indication of my opinion on the matter may be the fact that, upon first glance at the headline, I didn’t feel much need to read the rest of the article.  More doctors say no …

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We want our doctors to be perfect, but they’re human too

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A history of smallpox in America

Conditions and Diseases
June 14, 2011

This past Presidents’ Day, I thought it would be a good idea to talk briefly about the role that smallpox played in the life of our first president and it’s important role in the American Revolution. For those who would like to learn about this in greater detail, I would highly recommend the book, Pox Americana: The Great Smallpox Epidemic of 1775-82, written by Elizabeth A. Fenn.

In 1751, when George …

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A history of smallpox in America

MRI overuse is widespread, and dangerous to patients

Physician
June 13, 2011

MRI overuse and misuse really make me angry.

Did you know that a growing number of doctors don’t even read the tests themselves? Another shocking aspect of this industry is that some doctors will order an MRI because it’s quicker than doing a full examination. Rushing to an MRI can oftentimes erase clinical correlation, that is, connecting the dots between pain and what the MRI shows.

MRI is unnecessarily overused. In …

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MRI overuse is widespread, and dangerous to patients

Social media ROI for one practicing physician

Social Media in Medicine
June 13, 2011

This is a message that should resonate loud and clear with providers, institutions or members of the healthcare enterprise world  who are ruminating over the upsides — and potential downsides — of a wide reaching, multiple digital property: social media presence.

As Ted Eytan found out when he questioned the (anonymous) physicians on Sermo, many physicians are simply not interested in establishing an online presence.

“Risk” is the overwhelming variable they’re …

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Social media ROI for one practicing physician

Why doctors shouldn’t have to choose between medicine and family

KevinMD
June 12, 2011

For the past few Sundays, the New York Times has published provocative op-eds involving physicians.

The first tackled physician bullying.  Next was the cost of medical education.  And, most recently, the phenomenon of part-time, mostly female, physicians.

This is obviously a live-wire topic, sure to generate passionate commentary.

In the piece, anesthesiologist Karen S. Sibert goes over ramifications of part-time physicians.  …

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Why doctors shouldn’t have to choose between medicine and family

Medicare’s high cost end stage renal disease patients

Conditions and Diseases
June 11, 2011

Anyone who thinks America has the best health care system in the world ought to take a look at its miserable record on caring for end stage renal disease patients on dialysis.

About one of every five people who go on dialysis dies in the first year here, compared to less than one in seven in Europe and one in sixteen in Japan. Even after adjusting for age, gender, race …

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Medicare’s high cost end stage renal disease patients

Why private practice surgeons perform more open breast biopsies

Physician
June 9, 2011

A Florida study assessed the rate of needle versus surgical breast biopsies over a period of five years.

What we’re talking about here are non-palpable abnormalities that are identified on screening mammography. A mammogram report will come back that assesses the relative risk of an abnormal collection of calcifications harboring an invasive or pre-invasive cancer (staged on a scale from I-V). With such data, one is obligated, …

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Why private practice surgeons perform more open breast biopsies

Why families and advocacy groups accept the torture of dying patients

Physician
June 9, 2011

by Aroop Mangalik, MD

A man has lung cancer that has spread to the brain. The cancer in the brain has been growing despite full dose radiation. His lungs have failed and he has been on a respirator for 10 days with progressive worsening of lung function.

Despite multiple discussions between the doctors and the Intensive Care Unit’s team …

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Why families and advocacy groups accept the torture of dying patients

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