Wednesday, July 29, 2015

More on the Propublica Study of Surgeon Complications

Numerous organizations are focused on reducing complications, reducing hospital admissions, and looking for a means to determine if certain surgeons or hospitals are 'outliers' in terms of complications.

Most of these studies are intended to decrease costs as a result hopefully of this analysis. Even well designed studies such as Propublica's are fraught with incorrect assumptions. Statistics should only be taken at face value and individual case studies are imperative.  Many cases require a deep dyve to extract information that will improve safety and  diminish complications.

Some controversy and a deeper look into the Propublica Study reveal mitigating information about less than optimal statistics for some surgeons.

photo by Shutterstock

When a bad surgeon is the one you want: ProPublica introduces a paradox

As posted to  KevinMD by  | PHYSICIAN  

Case #1

Morbidity Hunter’s real name is Harjinder Singh. He migrated from Punjab and works in a safety net hospital in North Philadelphia. Singh wanted to work in Beverley Hills, but to convert his J1-visa to a green card, he had to work in an area of need. Once he started working, he liked his job. His daughters liked their school, and his wife liked the house they bought. Singh doesn’t have shiny teeth. He hasn’t appeared on TV, although his daughters tease that he can play Sonny from Exotic Marigold Hotel.
Singh’s colleagues named him Morbidity Hunter because he operates regardless of how sick his patients are. He never says no. Nearly all his patients are obese and diabetic. The school of public health sends students to shadow him to learn about polypharmacy. The hospital went on a spree of hiring hospitalists when Singh started.
His patients, straddling the Federal Poverty Limit, don’t rate him on Yelp. His patients don’t use Yelp. Even if they were informed consumers they would have to choose Singh, because there are very few orthopedic surgeons who are willing to operate on them in that zip code. His patients haven’t heard of Cherry Picker. They don’t ski, ballroom dance or run half marathons.
Singh, too, is good at his craft. Technically excellent, to be precise. You wouldn’t know that from looking at the rates of readmission, infection, and deep vein thrombosis in his patients. But the staff in the operating room know that, as do his colleagues, whom he has often helped out in tough operations. Even Cherry admires him.
Singh is not in for the money. He doesn’t make as much money as Cherry, but makes enough. He doesn’t operate for glory. He operates for professional pride — an ethereal concept that eludes some health economists.
It’s hard to zap the morale of this sturdy lad from the Punjab. But the data transparency movement achieved that. He always knew that operating on the sickest, poorest and most disenfranchised section of society was not going to be lucrative. But he never knew he was going to be made the captain of their ship — he was happy to captain the placement of their total hip — but what happened before or after they entered the operating room was not his fault, he felt.
People began to call Singh an incompetent surgeon. He objected, but he could not understand the logic behind the numbers which were incriminating him. His complication rates were the highest in Philadelphia. Numbers don’t lie, supposedly. This was too much for him to bear. He didn’t mind losing the pitiful bonuses that CMS was withholding from him, but the reason broke his heart: his poor quality.
Singh was puzzled by people who claimed to lose sleep over the poor. The chasm between their sentimentality and actions baffled him. Punjab began to make more sense than Philadelphia. But then Cherry invited Singh to join his practice in New York. Cherry promised Singh that he could operate on technically challenging patients. Grudgingly, Singh accepted the offer, which made his wife very excited about shopping for Indian food in Queens. She insisted, though, that Singh had to see a dentist first.
Homo sapiens have always sought redemption. Today it is through data. Numbers have replaced Yahweh and Indra. But, just like the old gods were, numbers can be moody, arbitrary and, occasionally, downright unfair. Numbers are a human construct, after all.
Case #2

Cherry Picker lives in the Upper East Side of New York. His patients give him great reviews on Yelp. His patients read every comment on Yelp before making any decision. Cherry Picker has a beautiful family. When he smiles, light refracts from his shiny teeth.
Cherry regularly appears on TV. He writes for the sleek, metrosexual publication, FHM. Cherry specializes in knee injuries in weekend warriors. His patients often call him from the ski slopes in Colorado, Whistler ,and Zermatt. Cherry is good at his craft. But his patients are even better at their craft — post-operative recovery. Cherry doesn’t actively seek such patients. His patients are selected for him by his zip code, reputation, long waiting list and Yelp.
Simpson’s paradox — where the conclusions are actually, and precisely, the opposite of what is inferred from the data. That is, for example, when a study shows the superiority of an inferior treatment, and vice versa. he data release by ProPublica is a reservoir of Simpson’s paradox. This means when the data says “bad surgeon,” the surgeon might, in fact be a Top Gun — a technically-gifted, Morbidity Hunter — the last hope of the poor and sick.

Aren’t you intrigued and perturbed by this paradox? This means that data may not be just telling half-truths, but flat out lying.

The truth is if you have a great outcome,  you think your surgeon is the best.  If it is less than optimal there is a wide range of reactions. Some surgeons have great bedside manners...sometimes they get away with 'murder' or complications. Some surgeons have no bedside manners. These surgeons may leave patients in doubt, especially if their outcome is less than optimal.

PPACA (OBAMACARE) The Good, the Bad and the Ugly

When the PPACA was passed by the U.S. Congress (heavily Democratic) it was largely an uninown law.  Several years later we know much more about it. As one reads the actual law the print becomes smaller and smaller as you develop nausea,  headache, and confusion.

Statistics out this month reveal how many more millions of people are now insured. That is the 'GOOD"

Analysis reveal the higher  deductibles, and co-pays are the "BAD".

Lack of accessiblity, the limited number of providers accepting PPACA policies, and a 'poverty algorithm defeat some from obtaining health insurance and the involvement of the Internal Revenue Service  are the "UGLY"

Ain't The Way To Die |

Published on Jul 28, 2015
"Just gonna stand there and watch me burn, end of life and all my wishes go unheard." Visit for more on how to start this conversation.

Lyrics and more here:

Based on the Eminem & Rihanna song, "Love The Way You Lie."

Lyrics by ZDoggMD (Dr. Zubin Damania) and Dr. Harry Duh.

Audio engineering, mixing, production, and chorus vocals by Devin Moore.

Thanks to Success 3.0 Summit for supporting this production and to:

Wake Up The Movie:
Storyworks Production Company
Director, Michael Shaun Conaway
Producer, Alex Melnyk
Editor, Sean Horvath
Colorist, Mark Anton Read

Special thanks to the residents and staff of the University of Nevada School of Medicine.

Please share widely...and thank you Dr ZdoggMD

Tuesday, July 28, 2015

What are the best three life hacks?

 by:  Dan HollidayRecruiter, Traveler, Runner, CrossFitter, Philosopher & Lover of History; 

You may be wondering what does the title have to do with Health Train Express ?

We are all on the train of life, and it is an express.  While I came up with this title almost ten years ago, it has served well all these years, providing a transportation through HMOs, Managed care, Health Reform, HIT,  the Affordable Care Act and so on and on.

Not so much "life-hacks" but things that have made me successful(ish):
  • Exercise really is the solution to so many of life's issues (moods, health, etc.).  It's not just hype.  My entire life has been changed in monumental ways because of exercise.  If you're not getting enough exercise (or unless you are one of the rare like 1% of people who genuinely can be healthy without it) then you are suffering in some way.  It doesn't have to be CrossFit or running marathons, but you should be exercising.
  • Make a list of your priorities (including people).  Update it as necessary, but refer to it frequently.  It will help you make decisions on what is important in life.  It's cold.  It's calculating.  But so are you, we all are; we all have priorities (and we hate to admit that we rank people and things, but you do, we all do -- I'm just honest about it and write it down; if you're in my life, you're on the list).  The difference between those who cannot prioritize and those that do is about two heartbeats in making decisions that most people agonize over.
  • It's better to do things than to have things.  I'm not rich, but I can do one or the other.  I can afford nice things. I could have all sorts of great shit that people would look at and desire.  I can travel and do things and have great experiences with my husband.  But I can't do both.  Doing things together builds your relationships; having things seems to distract away from what's important.
Okay, and one more:
  • If you have plans, have re-evaluation periods and benchmarks.  It's hard.  It ain't fun.  But if you don't have goals and dates that those goals need to meet, then you are unlikely to succeed in a lot of things you try to do.  Your goals should be flexible (mine change all the time), but the ones I have, have evaluation periods that I look back and think, "Why am I doing this?"  If I'm not on track to meet the goals, if I feel like I'm missing the mark (or that it's no longer worth it), I evaluate and change course.
Let's watch Dustin Garis' TEDxRenfrewColllingwood take on this:

Do you want to grow your material wealth ? or:

"Grow  your wealth of Life Profit"

So  you ask, What does this have to do with Health Care? Nothing, and everything. It should however place a proper priority on life on the Health Train Express.

In 50 years none of this will be relevant.  (I hope much sooner)

Obamacare rates to rise 4% in California for 2016 - LA Times

Peter V. Lee is the executive director of Covered California. James C. Robinson is a professor of health economics at UC Berkeley.

California's Obamacare exchange negotiated a 4% average rate increase for the second year in a row, defying dire predictions about health insurance sticker shock across the country.
The modest price increases for 2016 may be welcome news for many of the 1.3 million Californians who buy individual policies through the state marketplace, known as Covered California.
California's rates are a key barometer of how the Affordable Care Act is working nationwide, and the results indicate that industry giants Anthem and Kaiser Permanente are eager to compete for customers in the nation's biggest Obamacare market.
Leading up to Monday's announcement there had been a steady drumbeat of news about major insurers outside California seeking hefty rate hikes of 20% to 40% for Obamacare open
enrollment this fall.
Overall, 44% of Covered California customers said they found it difficult to pay their monthly premiums now, according to a recent survey. And some people have indicated that they feel shortchanged in terms of the doctors they can see and the service they get from their health insurer or the exchange when problems arise.
Free market forces can be a powerful tool to contain health costs. But for that tool to work, consumers need the support of an active purchaser that can go toe-to-toe with the insurers. Other states and the federal exchange would be wise to look at what's working in California.

Monday, July 27, 2015

Shopping for a Doctor Who 'Fits' - The New York Times

All newly minted physicians go through a learning curve. They have learned all the ABCs of medical science, and then some.

Life experience comes to us through dribs and drabs if we are fortunate, or it may hit us in the face all at once.

At times physicians must 'unlearn' best practices, ethics, and other ethereal values or face consequences.

At times bad manners, or poor judgment rather than a medical error results in a medico-legal situation. And there are many attorneys willing to help there, on either side.

Shopping for a Doctor Who 'Fits' - The New York Times

Second opinions are a normal part of my line of work. I specialize in rare diseases affecting the bone marrow, and feel privileged both to practice at a hospital where I can focus on these esoteric illnesses, and to be considered competent enough at what I do that people seek my input on their diagnoses and therapies. At the same time, I never discourage my own patients from seeking the opinions of others, as their conditions are unusual and serious, and frequently deserve advice from more than one doctor. It’s what I would ask for if one of my own family members became sick.

But that wasn’t exactly why this woman was seeing me. She had arranged this appointment because she didn’t like her other doctor, and wanted to see if she liked me better.
These kinds of clinic visits have also become a normal part of my practice.
Decades ago, when physicians worked within a much more paternalistic system, such “doctor shopping” would have been considered inappropriate. Your doctor’s medical opinions were considered authoritative, incontrovertible and often final. Patients who challenged them were labeled “difficult,” and worried about developing a reputation that would influence their care, both with their own doctor and with others – as in the 1996 “Seinfeld” episode called “The Package,” in which Elaine is blackballed from being seen in medical offices and tries to steal her own medical records to erase her “difficult patient” status.
In recent years, patients have become more empowered to demand both good care, and a good attitude. Given some of the stories I have heard, I can’t say that I blame them.
One patient recounted how, when she mentioned to her primary oncologist that she wanted to seek my opinion, he told her to take her medical records with her because if she did see me, he would refuse to ever treat her again.
Another patient called me from his hospital room to give an account of his recent interaction with a doctor who recommended a course of chemotherapy for his refractory cancer.
“When I asked some questions about it, she basically told me it was her way or the highway. This is a big decision,” he told me. “I don’t want to go into it lightly.”
I reaffirmed that he, and not the other doctor, was in control of his destiny and treatment options, and reviewed the possibilities with him so that he could make a decision. I then called that doctor to relay his choice, which happened to be what she recommended – but on his terms, where he was included in the process.
Other times the interactions aren’t quite as dramatic, but represent more of a dissonance of personalities. Patients feel their doctors may be overly confident, or not confident enough; excessively nurturing, or too aloof. Alternatively, they simply may not “click.”
It cuts both ways. Doctors may not like some of their patients.
Years ago, I was asked to care for a prisoner who had just been diagnosed with lung cancer. When I entered his hospital room, he was lying in bed in his prison jump suit, his leg handcuffed to the bed’s footboard, as two guards stood by his side. As I explained his diagnosis and treatment to him, he stared at me, unblinking, with hate in his eyes. Every hair on my body prickled until I left his room. A guard who followed me into the hallway told me why my patient was in jail: He had killed his wife using a hammer.
I did not like that patient. But I put my emotion aside and cared for him, without judgment and to the best of my abilities, because it was both my job, and my duty.
I worry that we are increasingly losing sight of why our patients are seeing us. It is not because they want to, but because they are sick – they are hurting, not us. In their moments of need, we should disregard any feelings of indignation if our patients seek the opinion of another, or our disappointment that they don’t immediately accept our advice. We should support them as they make decisions about their own health – even if those decisions don’t include us.
As I walked into the exam room to meet my new consult, I put on a warm, welcoming smile. I didn’t want her to feel the least bit uncomfortable about the reason for her visit. Because this was about her medical care, and not about anyone’s pride.
Dr. Mikkael Sekeres is director of the leukemia program at theCleveland Clinic.

Does Health Care need "The Donald" ?

The shock wave of Donald Trump is passing over the political landscape. The "Donald" has no patience for political correctness. He trucks no incompetence, and does not bear fools easily. Plainly he is in your face and does not accept standard answers for  problems we have all witnessed for what seems time immemorial.

I like him, his approach, and disbelieving attitude. First of all  he is a great actor, who won't allow himself to be upstaged.  If he goes down it will be with a flurry of the "Donald's" hair. All those who label him as a  fool or a 'jackass' are missing the point, and the more they label him, the more support he receives from potential voters, Republicans or Democrats.

All you politicos, Get it straight. The public is fed up with the usual committee decisions, passing of laws that are not enforced, the border, immigration, educational incompetence, a failed economic plan, and the unearned 'tenure' of our elected representatives, and congressmen and senators who don't read or understand the bills they sign. That would fail you in elementary school. So why do we allow or condone this in our representatives?

Trump approaches issues like his flagship trade mark, the tsunami-like hair style...he leads with it, it washes over you and then  sucks you down and back.

Trumps says what we all have thought or felt, but would not say out loud. We are all too afraid to do that. We might lose friends, jobs, money, family or some other valued asset in our lives.

Frankly "Scarlett, I don't give a damn !" Donald Trump
would say.

The same can be said about health care and  health reform.

Such as it is we have had a constant flow of "experts" managing our health system.. It's a bit like the ship of fools, who are appointed because of their expertise on health.  Once in command they realize how they are outgunned by bureaucrats, and politicians who are experts in deception, half-truths, believers in algorithms and who knows what else.

For Example

The Players at HHS and CMS

Which leads most of us to ponder about our gut feelings regarding the Affordable Care Act, Accountable Care Organizations, Meaningful Use, and Value Based Reimbursements.

So,  who will be the "Donald" for Health Care?  Applicants apply here.