[quote]Derek542 wrote:
Are you also doing the transgender surgery? [/quote]
oh balls…
[quote]bam7196 wrote:
[quote]StevenF wrote:
[quote]MementoMori wrote:
I once spent 14 hours waiting for surgery for appendicitis when I was 13 years old.
During that time I waited 10 hours in the ER waiting room. Twice I was brought in for ultra sounds to determine the issue. The second time I asked the doctor why he couldn’t watch the previous doctor do instead of doing it one after the other. The doctor ignored this and said “yep, it’s probably appendicitis.” At that point I was sent back to the waiting room for another couple hours. When I finally received a bed 10 hours later my mother begged the doctors to give me pain killers. I don’t remember that point as I’d already blacked out from pain.
By the time I finally got into surgery my appendix had ruptured. After surgery my mother asked the nurses if I had been stitched up. They didn’t know, and refused to ask the doctor because he was notorious for poorly treating the nurses. When he finally came to see me my mother asked him. He walked up to me and said, “lets check.” He grabbed my dressing and ripped it off my stomach in one yank, nearly pulling me out of my bed in shock and pain. “Looks like I left it open…” and with that he walked out.
I required a home nurse the rest of the summer as I developed what I’m told is called “granulated skin cells” Essentially my wound healed outward without ever sealing in the middle. The wound had to be cauterized several times throughout the summer until it sealed. Given the poor healing process, and the necessity of cauterizing the abdominal muscles, it developed into a hernia.
All for a quick appendectomy.
[/quote]
coming soon to America… [/quote]
See my post above. Definitely not.
Also granulation tissue is what’s supposed to happen to a wound. There are incompetent/mean-spiritied people in every profession.
[/quote]
Lived in such a system for decades, definitely yes-
Either rationing or worse outcomes those are the outcomes in a planned economy.
Tertium non datur.
orion, would you mind explaining why there is no middle here?
Also, what is often presented as “rationing” can be a misnomer. For instance, the health systems in which I have worked obtain imaging WAY too often, even when a good history and clinical exam do not suggest the need for it. It is pretty tough to go through an ER in the US now with any sort of complaint that even remotely resembles a neurologic problem without getting a head CT. Not only is this excess radiation for the patient, it’s also a fairly expensive test to obtain and to have read. I am willing to bet that intracranial imaging (especially MRI) is going to need much better justification in a few years. This may be called “rationing” but, again imo, the term used in this way is somewhat misleading.
It absolutely will not be a perfect system. No doubt about that. Did you read my post above about outcome-based payments or cost-benefit ratio in the US currently? Any thoughts?
[quote]bam7196 wrote:
orion, would you mind explaining why there is no middle here?
Also, what is often presented as “rationing” can be a misnomer. For instance, the health systems in which I have worked obtain imaging WAY too often, even when a good history and clinical exam do not suggest the need for it. It is pretty tough to go through an ER in the US now with any sort of complaint that even remotely resembles a neurologic problem without getting a head CT. Not only is this excess radiation for the patient, it’s also a fairly expensive test to obtain and to have read. I am willing to bet that intracranial imaging (especially MRI) is going to need much better justification in a few years. This may be called “rationing” but, again imo, the term used in this way is somewhat misleading.
It absolutely will not be a perfect system. No doubt about that. Did you read my post above about outcome-based payments or cost-benefit ratio in the US currently? Any thoughts?[/quote]
Well frankly because thats whats always happening?
I could go into why but that would take long and I have a terrible headache.
In the case of Austria where we do have a single payer system (not really, but for all practical purposes) the overhead is a fraction of one percent.
Which is actually true.
However, the true costs of a planned system does not lie in the overhead.
It lies in the lack of competition, the lack of innovation, political influence on the process which leads to enormous capacities that are unreasonable for such a small country but if Styria has an superfluxcapacitator, Lower Austria wants one too.
At the same time though, our doctors are overworked, underpaid, are forced to do shifts that are downright dangerous (dont want to be in an ER if the doctor was on 72h stand by).
Meanwhile in Canada:
I especially recommend the end of that segment.
[quote]bam7196 wrote:
For all of you lamenting the implementation of the ACA, it is certainly not all bad. Coincidentally this morning we had a recap of our department’s observed/expected in-hospital mortality. The numbers for the hospital system and national averages were also shown. In addition we reviewed our door-to-needle time for tPA for the past several months. All of these criteria are now going to be judged against a national standard and reimbursement is going to depend directly on performance. My example is certainly a bit different than those that came before since it is mostly focused on critical care and stroke, but it’s the only direct example I can vouch for.
The changes will not occur just with inpatient care. There will also likely be a nationally-mandated system for 7 and 30 day direct calls to patients post-discharge to check up on their progress (admittedly this is a cost-saving measure to avoid re-admission, but still it’s a great addition and something that NEVER gets done now). This is unlikely to involve all discharge diagnoses, but that would be a bit excessive imo. In addition there is going to be an open national database where health professionals are graded subjectively by their patients.
While there are certainly problems with the above system/ ACA, at the very least it should reassure you that payment is going to be based on outcome moreso in the future than it is now. This will help to ensure in part that patient care doesnt suffer even though we’re entering a somewhat new era. On top of that, remember that we currently spend 5% more of our GDP on healthcare than any other nation on earth, yet we have significantly worse outcomes than many, many other countries. The new changes will not be perfect but something does need to change.[/quote]
Well, then. Here is an opposing voice to the nonsense known as “Pay for Performance.”
nejm.org/doi/full/10.1056/NEJMp1312287?query=featured_home
While I like that that particular article was in NEJM:
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It is an editorial
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I work in a hospital and have core measures set as a standard by the hospital system (for whom the editorial states that PQRS drives changes)
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Again, as I said in my original post, my reference was to observed/expected mortality, which is easily measurable and ubiquitously reported. I openly said that this does not apply across all facets of patient care.
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Some of this is a strawman, I have not heard of radiologists potentially being judged against a national standard. That is kind of ridiculous.
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For the third time, it is not a perfect answer. My post was simply an effort to assuage some of the feelings toward ACA that may not be well founded.
My grandfather waited months for cancer surgery, under Socialized Medicine.
He got so tired of waiting, he went home in his fucking bathrobe, and still not had an actual date set for his surgery.
[quote]bam7196 wrote:
While I like that that particular article was in NEJM:
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It is an editorial
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I work in a hospital and have core measures set as a standard by the hospital system (for whom the editorial states that PQRS drives changes)
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Again, as I said in my original post, my reference was to observed/expected mortality, which is easily measurable and ubiquitously reported. I openly said that this does not apply across all facets of patient care.
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Some of this is a strawman, I have not heard of radiologists potentially being judged against a national standard. That is kind of ridiculous.
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For the third time, it is not a perfect answer. My post was simply an effort to assuage some of the feelings toward ACA that may not be well founded.[/quote]
You seem to be a reasonable person so it may serve you well to re-read the editorial–an invited editorial, note, in the NEJM–its references and comments. (And note, too, these authors support the ACA.)
The tyranny here is that of the clipboard wielded by a nurse or a clerk. The concept of quality is reduced to that which can be measured in minutes or checked off a list. Hence, the quality to which you refer, tPA time, joins some utter nonsense only because it can be measured, and not because it reflects true quality or patient benefit. (Lipid panels within x days, heparinoids for DVT prevention–which has been proven not to prevent morbidity or mortality, etc. etc.) And yes, you find PQRS ridiculous for radiologists; I find it ridiculous for about 98% of outpatient medicine.
(Like pornography, I know quality when I see it. It has been estimated that as much as 80% of the “national guidelines” are based on published nonsense, bad articles, unreproducible results, etc. Please see multiple works of John Ioannidis, including Why Most Published Research Findings Are False - PMC
…)
The real use of the “clipboard quality measures” is as a cudgel, a cudgel to deprive hospitals and physician practices of just remuneration. It is happening. While I happen to agree that quality improvement is a constant struggle, I also recognize that the penultimate judge of quality is a committee, and running dead last is–government.
I dont know if you write as you do because that’s genuinely who you are or if you think it is advantageous, but it seems you’re intentionally verbose when you need not be. It makes the central ideas of your post difficult to ascertain at times.
Are you suggesting that door-to-needle time for tPA is not linked to clinical outcomes?
Are you attempting to state definitively that systemic anticoagulation for DVT is of no benefit as far as outcomes? You insinuate no debate on the subject.
Again, my main point was stroke and critical care. Not outpatient medicine
We also as a nation seem to have resigned ourselves to saying “well, other people have tried a paradigm shift and it didnt work out perfectly, so the entire idea of moving in this direction must be wrong.” Not saying that’s your POV; just thinking out loud. The idea that Congress is inept, which they are, should not stop us from attempting to facilitate an improved system.
[quote]bam7196 wrote:
I dont know if you write as you do because that’s genuinely who you are or if you think it is advantageous, but it seems you’re intentionally verbose when you need not be. It makes the central ideas of your post difficult to ascertain at times.
[/quote]
I am sure you are up to the task.
No
Yes; the guidelines are of no benefit. Proven. And the guidelines still stand despite proof of lack of benefit.
Understood. Decreased morbidity of stroke and MI are important. (Critical care is a broader issue). Perhaps real quality will occur when paramedics give the tPA in the field; perhaps not. My cavil is that clipboard medicine is very overrated as a measure of quality.
[quote]
We also as a nation seem to have resigned ourselves to saying “well, other people have tried a paradigm shift and it didnt work out perfectly, so the entire idea of moving in this direction must be wrong.” Not saying that’s your POV; just thinking out loud. The idea that Congress is inept, which they are, should not stop us from attempting to facilitate an improved system.[/quote]
So much time and money is wasted on well-intended notions. When real evidence will show that P4P does not work to improve broadly the quality and the desired outcomes, you will no doubt agree with me. In the mean time, it is merely broadly unworkable, unrespected, and inapplicable to the greater part of medical care and its costs.
To be clear, I don’t think my botched appendectomy is a judgement on Free Health care, but rather that doctor. My father last year was diagnosed with prostate cancer on Halloween, he had his surgery and was in remission by February. Same goes for my grandfather who survived both prostate cancer and leukemia.
If the worst the US has to worry about is having a medical system like Canada they’re not nearly as poor off as some may think.
[quote]MementoMori wrote:
To be clear, I don’t think my botched appendectomy is a judgement on Free Health care, but rather that doctor. My father last year was diagnosed with prostate cancer on Halloween, he had his surgery and was in remission by February. Same goes for my grandfather who survived both prostate cancer and leukemia.
If the worst the US has to worry about is having a medical system like Canada they’re not nearly as poor off as some may think.[/quote]
There lots of caring/professional practitioners around, but that docotor you had was appalling.
That aside, I have never understood the scheduling of student doctors/registrars/doctors for 72 hours straight on duty. There is no way to get proper care with a tired/sleepy doctor.
There is also appalling nutritional ignorance in the system -seen hospital food? You really have to know what you’re ordering there.
Etc.
"Understood. Decreased morbidity of stroke and MI are important. (Critical care is a broader issue). Perhaps real quality will occur when paramedics give the tPA in the field; perhaps not. My cavil is that clipboard medicine is very overrated as a measure of quality. "
Germany is already equipping ambulances with CT scanners and giving tPA in the field. Outcomes are improved.
Not sure what you mean by “real quality”. Door-to-needle time is undoubtedly imperative in Modified Rankin-based outcomes. I think you agreed with this by saying “no” to the earlier question.
Please link a study finding that systemic anticoagulation following DVT does not improve outcomes. I cannot find anything in the literature, presumably because it is standard of care and would be considered unethical to assign patients to the control group.
“So much time and money is wasted on well-intended notions. When real evidence will show that P4P does not work to improve broadly the quality and the desired outcomes, you will no doubt agree with me. In the mean time, it is merely broadly unworkable, unrespected, and inapplicable to the greater part of medical care and its costs.”
Do you have anything other than the above editorial that shows pay for performance doesnt work in medicine? I can tell you that our department has improved significantly with regard to goals of care simply by being prompted, without any direct monetary compensation. This directly contradicts your ideas on the matter; although it’s a single department, it’s the only direct evidence to which I can attest.
Just out of curiosity (and knowing that we can obviously say whatever we want about who we are on here) are you a physician? If so, what field?
[quote]bam7196 wrote:
"Understood. Decreased morbidity of stroke and MI are important. (Critical care is a broader issue). Perhaps real quality will occur when paramedics give the tPA in the field; perhaps not. My cavil is that clipboard medicine is very overrated as a measure of quality. "
Germany is already equipping ambulances with CT scanners and giving tPA in the field. Outcomes are improved.
Not sure what you mean by “real quality”. Door-to-needle time is undoubtedly imperative in Modified Rankin-based outcomes. I think you agreed with this by saying “no” to the earlier question.
Please link a study finding that systemic anticoagulation following DVT does not improve outcomes. I cannot find anything in the literature, presumably because it is standard of care and would be considered unethical to assign patients to the control group.
“So much time and money is wasted on well-intended notions. When real evidence will show that P4P does not work to improve broadly the quality and the desired outcomes, you will no doubt agree with me. In the mean time, it is merely broadly unworkable, unrespected, and inapplicable to the greater part of medical care and its costs.”
Do you have anything other than the above editorial that shows pay for performance doesnt work in medicine? I can tell you that our department has improved significantly with regard to goals of care simply by being prompted, without any direct monetary compensation. This directly contradicts your ideas on the matter; although it’s a single department, it’s the only direct evidence to which I can attest.
Just out of curiosity (and knowing that we can obviously say whatever we want about who we are on here) are you a physician? If so, what field?[/quote]
To be clear, I was pointing out that the prophylactic use of heparinoids to reduce the risk of DVT among (medical) inpatients was proven ineffective, and yet it remains a clipboard criterion of quality. For example:
The editorial has references; that should be a good start for you. Please read the comments–do not dismiss them as “anecdotes”–and follow the rebuttals which will be published in a few weeks.
(And yes, I am a physician, boarded in internal medicine and a subspecialty, who after 25 years resigned from a clinical professorship at a reasonable university medical school.)