Category: Physicians

What would Mickey do?

published date
January 10th, 2007 by

I’m taking a lot of flak –some deserved, most not– for yesterday’s post about my recent ER experience. When I have a moment I’ll address some of the comments. Meanwhile I asked Mickey (who’s a pediatrician) for his perspective. Here it is:

If you suspect a fracture outside of regular office hours and a doctor can’t rule it out over the phone you should go to an ER.  The solution is to make the ER faster.
When I was a resident our chief of service told us that families should not be kept up after 10 PM for scheduled admissions.  This is reasonable, but often 5 families come in for scheduled admissions after 6 PM and one resident can’t admit them all and take care of other priorities (such as the ER) without some people waiting a long time.  We decided amongst ourselves to create an overflow system in which we’d ask other residents on the team to stay late to do some of the admissions.  We needed to invoke this backup system only about 10% of the time, but it made things run more smoothly, and everyone got more sleep.  One of my most memorable nights on call began with my diagnosing a tumor that I noticed incidentally on a skull X-ray of a kid hit by a car while bicycling.  After that, one after another fascinating patient showed up, and each got great care because I got two other residents involved, people who are today among the top clinicians in the field.  We did a great job and no one waited around for 5 hours.
Hospitals should use similar backup systems to cope with peak load problems.  Ironically, measures taken to reduce doctors’ working hours have limited this flexibility by banning the others on the team from staying around.  Yet, using such a flexible system, everyone got more sleep.
Two of us from that memorable night wrote a letter to the NYT that appeared on June  8, 1987 arguing for such a backup system instead of heavy-handed regulation of doctors’ work hours.  The WSJ got me to expand this as an Op-Ed, run on 18 June.

This could have been done in 5 seconds but instead it took 5 hours

published date
January 9th, 2007 by

In case you don’t want to read this whole story, the moral is to try to get Dr. Robert Lindeman of Natick Pediatrics as your pediatrician if you live anywhere close to Natick, MA.

On December 23rd my preschooler came home from a play date with an aching, swollen foot. No one knew exactly what had happened except that he’d fallen. The next day he was still complaining about it and limping badly. (He’s not a big complainer or limper.) Normally I dread any interaction with the health care system so I would have ignored the injury and hoped it got better. But it was the day before Christmas and two days before we were leaving the country for a week.

We went to a family social function on the 24th. There were plenty of doctors there, including pediatricians. We asked one pediatrician (whom we don’t know well, but who practices pediatrics in the ER) to have a look. She took off my son’s shoe, had a look, and said she wasn’t sure. Her dad happened to be there, too. Turns out he is a pediatric orthopod! He had a look and said he couldn’t see through skin (since he lacks X-ray vision) and that he didn’t know if it was broken. Both told us that if it was a Jones fracture it could be serious and require treatment.

Then my wife saw our friend Dr. Lindeman, and asked him. He didn’t take off my son’s shoe or talk to him but said:

“It’s not broken. I can tell by the way he’s putting weight on it. Don’t worry about it.”

When we got home we called our pediatrician’s office. Our excellent pediatrician, Dr. Patricio Vives (old school, no website to link to), wasn’t around on Christmas Eve. The person covering for him said she couldn’t tell what was wrong and suggested we might want to go to the ER for an X-ray for “peace of mind.”

Oh no!

I took my son to Children’s Hospital and prepared for the worst. Good thing I did. Rather than complain about all the details I’ll just say it was a 5-hour experience, which included 4 hours and 45 minutes of waiting, 10 minutes in radiology, and 5 minutes with the doctor.

At one point (3 hours or so in) I was told –when I went to the desk and asked nicely– that we were next on our “track. ” (They have different tracks depending on whether orthopedic/surgical, medical, etc.). Around the 4 hour point, a staffer came out with a clipboard and after seeing our name toward the bottom of the list said, “you must have just come in.” I have to admit I almost lost my cool at that point. A few minutes later she came back and more or less admitted they’d lost track of us.

Who knows how long we would have waited after that. Luckily one of the physicians recognized our name and had us called in. It turned out to be another friend of ours. She saw my son, told us the radiology report was negative, and then had my son stand on his toes. As soon as he did that she concluded he was fine.

This experience was kind of embarrassing for me (and of course a big time waster). What I take away from it is to listen to advice from people you trust and don’t ask the opinion of people you don’t know well. If we hadn’t asked the first pediatrician and pediatric orthopod I just would have listened to Dr. Lindeman and not bothered to call the person covering for our pediatrician. (I’m pretty sure that if Dr. Vives had been around he would have steered us properly.) It also would have been nice to have a consumer-friendly decision support site, which could have taught me the tiptoes trick and saved my time and my health plan’s money.
So let me at least put in a proper plug for Dr. Lindeman (since I didn’t pay him for his quick assessment). He’s a first-rate office-based pediatrician with MD and PhD degrees from Columbia University. He’s board certified in pediatrics and pediatric pulmonology. He uses secure messaging with patients and families (though sadly he’s not using RelayHealth). He also handles call himself, rather than farming it out to someone else.
I don’t live anywhere near Natick, but anyone with kids who does should check his website or call his office at (508) 655-9699.


May 31, 2007

Yes, folks, I’m referring to the now-famous Flea blogger, so this post is getting a lot of hits today. I stand by my endorsement of Dr. Lindeman, which is based on ever-so-much-more than this particular anecdote. You’ll see a bunch of critical comments below from people who don’t have firsthand knowledge of this case and don’t know Dr. Lindeman. They’re off the mark IMHO.
David Williams

I guess we’ll have to think of another reason to oppose single payer

published date
January 8th, 2007 by

If there’s one thing everyone hates about single payer health systems it’s waiting lists for treatment. The trade-off is that costs are lower in single payer systems and everyone has access to care.

We can rationalize the situation in the US by saying we’ve decided not to make the trade-off. We’ve decided as a country that we don’t wan to “ration” health care or artificially limit its supply. Assuming you have access to the system you should be able to get as much care as needed to make you better.
But maybe there isn’t a trade-off. The US spends more on health care per capita and as a percent of GDP than anywhere else in the world. Massachusetts is the highest spender in the US. And Boston is the capital of the state and of its health care system.

Yet according to a new study reported in the Boston Globe (Dangerous delays to see skin doctors; Hub patients wait longest, study says), patients in Boston wait an average of 10.5 weeks to see a dermatologist for a “changing mole” –perhaps the closest thing in dermatology to an emergency. At the Brigham and Women’s Hospital, patients wait 3.5 months on average for a routine visit!

No one can really figure out what’s going on, especially when Boston has so many dermatologists.

  • Some physicians say the data must be wrong
  • Others cite the expansion of cosmetic services
  • Others blame it on the high percentage of researchers

In any case, no one’s accountable. (By the way this is not the first time physician access in Boston has been shown to be wanting.)
Just for kicks, I had a look at the UK’s National Health Service website, which has detailed, up-to-date information on waiting times by specialty. I looked at the “Provider Based Hospital Waiting Times for 1st Outpatient Appointments: England,” and checked the “Effective length of wait from receipt of GP written referral request to first Outpatient attendance (weeks). I’m not expert in reading these tables –so maybe I’m reading something wrong– but according to my calculations:

  • 37% of patients were seen in under 4 weeks
  • 63% in under 8 weeks
  • 98% in under 13 weeks

These numbers aren’t directly comparable with the Boston statistics. Still, it shows something terribly wrong with health care in my fair town.

Who’s afraid of the big bad debate?

published date
January 8th, 2007 by

The American Society of Hypertension (ASH) has taken a lot of heat from those (including the journal Hypertension) who think it is too cozy with the pharmaceutical industry. Responding to the pressure, ASH scheduled a panel discussion on “Conflicts of Interest” for its upcoming conference. However, the society then canceled the session –calling it one-sided– and this was reported in the Boston Globe (Medical group puts stop to talks on drug-firm ties). Once news of the cancellation got out it caused more controversy; now ASH is reversing course again.

This time, according to the Globe (In shift, medical society to hold panel), ASH plans to invite advocates of pharmaceutical company involvement in addition to industry critics. That has the critics (including Harvard Medical School professor Jerry Avorn and former New England Journal of Medicine editors Marcia Angell and Jerome Kassirer) up in arms.

“It seems to be standing the whole thing on its head,” said Angell. She said the original intent of the panel had been to provide a counterweight to the drug industry’s sponsorship of scientific papers and physicians at the annual meeting.

“This seems like a very different panel than the one originally proposed,” Avorn said. “Those two individuals [the industry advocates] will be expressing views that are quite different from those that were originally envisioned.”

I don’t know why Angell and Avorn are complaining. Angell’s opposition, in particular, seems silly. Does it really make sense to balance one biased part of the conference with another biased part? I say get all sides in a room and argue it out in a lively debate. Certainly the drug companies deserve a chance to put forth their arguments. If the room is full of people with the same views no one will learn much.

It would also be useful to have some participants who aren’t physicians. A patient advocate or economist, for example. One reason physicians and pharmaceutical companies have become so intertwined is that physicians don’t understand economics very well.

Henry Ford regulates pharma reps

published date
December 19th, 2006 by

The Henry Ford Health System is banning free lunches and gifts by pharmaceutical and medical equipment sales reps, starting January 1, according to the Detroit Free Press. Representatives will also have to schedule appointments with physicians and pay a $100 certification fee to Henry Ford before being allowed to do so.

“The evidence shows that when physicians are exposed to pharmaceutical representatives, their decisions are different,” Dr. A. Mark Fendrick, a U-M drug price specialist, told the Detroit Free Press. “It is very unusual to find generic drugs in a physician’s sample closet.”

The program is portrayed as a way to keep industry in line, but I look at it as part of the maturation of the relationship between pharma and docs. Sales reps buy lunch and provide gifts because doctors want that to happen; many expect it as a kind of entitlement. It’s just as well to have that practice end. I’d suggest Henry Ford use that $100/rep tax to fund an education program for physicians to help them get the most out of their interaction with drug reps. Maybe an online course to explain industry economics and help doctors ask the right questions.

There are at least a couple of companies I can think of that could benefit from Henry Ford’s decision:

  • PreferredTime, which schedules rep appointments with physicians
  • Medvantx, which makes machines that provide generic samples in doctors’ offices