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New Beginnings

           

A little over a year ago I was involved in a 50 car pile up on my way to work on Interstate 70 outside Hagerstown, MD during a freak snowstorm. The accident claimed 2 lives as well as caused numerous serious injuries. My vehicle, which steered clear of most of the carnage (although ended up being totaled), was nearly hit by a tractor trailer as it lost control and skidded off the road into some woods barely 10 feet from where my vehicle had stopped.

I mention this because I frequently drive by the scene of the accident. Over time I have seen the area go from torn up grass and downed trees, to a visible hole in the landscape to today a single tree bent among all the brush as the sole reminder of the events of that fateful day. Whenever possible I glance that way and think about that day, how close I came to a serious injury or death and say a small prayer for those who were not as fortunate as I.

I reflect on the events in light of the dramatic changes we will see in the next several years as health care changes. With the passage of the new law many are unhappy, some see and end to all that is good in our systems while others hope (granted an overused word in this day and age) for a chance for America to provide for those that, in some way, have been left behind in our country.

The ultimate success or failure of this new world will rest on the shoulders of the everyday doctor who seeks to provide quality care and be compensated a reasonable amount for what they do with less hassle and less risk of being sued. Is this a reasonable outcome to expect? As most things do it all depends on your perspective. M Scott Peck in his famous book “The Road Less Traveled” opens it with the statement that ‘life is difficult’. Indeed it is and always will be. The key resides in how we respond to the difficulties placed before us.

The one lesson I did learn in that fateful few seconds as the tractor trailer passed my car is that every individual (and indeed every country) is on their own road less traveled. No person or country is perfect and each has legitimate points to offer as we seek to move forward on this path. The most important points are often made by those with the quietest voices; the disenfranchised, powerless and those without a high paid lobbyist. As most people, I have tired of the screeching and rhetoric of both political parties. What we need is a radical movement to the center!

Just as the area of forest has grown in along the side of the road, the wounds of today’s political fights will heal over time. We have work to do to improve upon what has passed. After all, like life, democracy is a work in progress. I suspect many of us will be working just as hard tomorrow for our patients as we do today. Will the future be better? It all depends on your perspective.

Angelo Falcone, MD

The cost of health care and who is going to pay?

I’m sure we’ve all been entertained by the debate in Washington regarding health care and where we are headed. I give credit to President Obama for trying to have all the participants in the room, even if it was mostly political theater. Perhaps the best comment I heard is the suggestion to lock them all in the room in the Blair House and not let them out until they came to an agreement on a piece of legislation. Of course the issue would be whether it would require a simple majority or not to pass.

Like many physicians I continue to evaluate and treat the patients who present for care. Shockingly in a ‘broken’ system we continue to schedule physician appointments, operate hospitals, deliver medical supplies and get our medications at the local pharmacy. So what does all this talk of reconciliation and ‘nuclear option’ mean to most docs. I get the feeling most of us will find some way to survive. More regulation, of course, and more challenges on how to continue to manage seeing patients and keeping out practices alive as functioning businesses.

In the back of our minds I think docs know the future will hold extreme challenges. When you look at graphs such as this one from a recent National Geographic article you can’t help but wonder how long this difference, which is accelerating, can be tolerated by our country.

I’m sure much can be argued regarding the statistics involved. What can’t be argued is that there is a significant disparity between the US and the rest of the world. Is this a bad thing? I guess that depends on where you stand regarding the debate. How much more than the current 16% of the total economic output of the US can be spent on healthcare? Same answer as the previous question although I think at some point the system may collapse under its own weight.

I had the opportunity to testify in Annapolis recently on some health care legislation. As part of this process I spent 8 hours listening to the testimony involved in other bills which preceded my issue. It was enlightening to hear from individuals to CEOs of health plans on the struggles that many faced. Granted I had a little less sympathy for the healthcare CEOs. The underlying issue was the significant accelerating costs which have continued to layer year after year over the last decade.

There is no doubt that there is significant waste and overuse in the current system. The aggressiveness with which we approach care towards the end of life certainly contributes to the cost escalation. Of course when it’s my life that you are talking about than no sum is too great! That is not to say there aren’t areas of flagrant waste in our system which needs to be addressed. There is and always will be.

We also know there is a significant practice of ‘defensive medicine’ by very good docs. In my specialty of emergency medicine I know the vast majority of patients I admit with chest pain are unlikely to have an acute cardiac event. That said there is no way I can assume the risk of missing that atypical presentation of acute coronary syndrome that may result in a patient’s death or having and MI when we know the malpractice attorneys will be circling to claim medical malpractice. It is simply the world in which most emergency physicians live. I’m sure every specialty has their areas of defensive medicine practice that contributes to the burgeoning cost of care.

I was curious to know where the dollars are spent in health care and came across this graph:

National Health Expenditures, 2007

Total = $2.241 Trillion

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.

Of course as we know the cost of pharmaceuticals and new medical devices is continuing to make up a larger and larger percentage of the graph. The price of progress, perhaps. It is obvious looking at the graph where the significant impact needs to come when we talk about ‘bending the cost curve’ come. Just like most large business entities we need to go where we spend the money. In our case that is the areas of hospital care and physician compensation.

Does that mean that physicians are headed to poverty? Of course not. I think physicians also need to realize that there will be some degree of ‘give’ wherever we end up. Like some docs I am willing to ‘give’ in exchange for less hassle regarding filing of multiple forms and protection from frivolous lawsuits when we don’t diagnose the 35 yo patient with chest pain and no risk factors who turns out to have an MI due to atypical symptoms. Patients also need to understanding that outlandish expenditures of care with little return needs to be reigned in. This involves sometimes difficult conversations about not getting the CT scan or treating with the latest cutting edge therapy that may give very little in terms of life expectancy. The biggest ‘crisis’ in health care in America is our general lack, as a society, to assume responsibilites for our bad habits; whether that be smoking, obesity or lack of exercise.

These are all difficult issues and it is not suprising that there is heated debate on where we are going to go, who is going to pay and how we are to get there. The great thing about America is we will aggressively debate the issue and come to some compromise that many will complain does not address the issue. It is probably the same debate we have had for the last 2 centuries on issues critical to our country. The fact that we do so without violence is a lesson we give to much of the rest of the world. As someone once said (apologies for not citing the source) ‘ The Americans will get it right, after they have tried all the other possible options’.

Angelo Falcone, MD

What I Love About America

There are many things wrong with our country. Americans are selfish, overweight, insensitive and uncaring. Some would have you believe we are the Great Satan and a justifiable target because of the simple fact of who we are and where we live. We are also some of the most generous human beings on this planet.

As I watch the events unfold in Haiti I have witnessed the greatness of America. We have individually given nearly $500,000,000 in charitable donations in a little over a week. We have sent Urban Search and Rescue teams from across this country within 72 hours of the earthquake to a place many of us have never been to rescue people we will never know. We have deployed the largest hospital ship in the world completely staffed by military medical personnel to render care to a country that has little left of its medical system. Our Soldiers and Marines are there helping to restore order and distribute badly needed humanitarian aid to people in desperate need.

We are not alone in these efforts as many countries throughout the world have contributed to this unfathomable event of human suffering caused by the earthquake. Indeed as we see the images and hear the stories of suffering each of us is moved to do SOMETHING. While many expect our governments to do the heavy lifting of this effort it is the individual American that has most inspired and touch me.

There are many examples of individuals simply heading down to Haiti, either through organized relief groups or on their own to lend a hand. Several members of our emergency physician group, Medical Emergency Professionals (MEP), are there providing care and comfort. Emergency physicians Drs Rafi Malik and Janelle Martin from Washington County Hospital are working through relief groups. One of our physician assistants from St Mary’s Hospital, Mark Hayward (who also happens to be an ex-special forces medic), is working with a self organized team, called Team Rubicon, and they have quite a story to tell.

Team Rubicon was organized by former Marines Jake Wood and William McNulty. They solicited the help of people with search and rescue as well as medical skills. The remarkable thing is he did it online and using their network of connections to arrive in the Dominican Republic and link up with Brother Jim Boynton from a Jesuit Mission near the airport. Their stories are amazing and can be followed online at Facebook Team Rubicon or MEP (Medical Emergency Professionals) as well as Jake Wood’s blog at http://blog.teamrubiconhaiti.org/

After landing in the Dominican Republic and securing entry to Haiti their team went to an area of Port-Au-Prince near the Jesuit Mission and began treating patients. Their team provided the first medical care to the residents in this area since the earthquake. To think that in less than a week a group of individuals was able to organize themselves, secure travel and get into that area with little to no government support speaks volumes about what can be done by a few committed individuals. It also speaks about what is best about America. It is a story that is rarely told today and more common than most realize.

So whether you are one of the select few who travel to a far away place to provide relief or someone who donates your time or money in other ways to support this effort I offer you thanks and prayers for your good work. May we continue to offer that generosity more frequently in the future.

Angelo Falcone, MD

New Decade, New Challenges

As we welcome a new decade, I’ve been thinking a lot about perspective. This past decade has been marked by terrorism (at home and abroad), economic collapse, home foreclosures, H1N1 and regime changes. Not a very upbeat decade, as decades go. Ronald Reagan spoke of that bright shining city on a hill and challenged us all to work to have the future we all desire. Is that still possible and what will that future look like?

In 2000, little did anyone realize that there was something called Facebook, Twitter or the iPhone. Today many can’t imagine our lives without them. In emergency medicine, we have seen amazing developments including drug eluting stents, advances in trauma care, explosion (not all good) in the use of CT scans and bedside ultrasound impacting our practice in ways we never thought possible.

What will this decade bring for us who practice in the ED and healthcare in general? Will it bring access to primary care for our patients? Will we be paid less for what we do? How much more “hassle factor” can we take while still providing high quality care? Will the overall cost of care be lowered? Depending on where you stand in the political spectrum, your answer will be very different.

What I do know is that no one will be able to predict what this world will look like in 2020 (with any certainty). I am also sure that while some say the days are bad now we are certainly not engaged in a Civil or World War. Our economic crisis does not compare to 1929 with 25% unemployment. H1N1 is not the Great Influenza pandemic of 1918 where 20-40 million died worldwide.

Which leaves us looking at that city on the hill. There will be a thousand reasons why we can’t reach it. Too far, too much regulations, bad weather, people working against us, not enough water on the journey just to name a few. Does that mean we shall just give up because it’s too hard? Of course not.

In the last 200 odd years, there have been thousands of reasons why our ancestors shouldn’t have traveled to America. For some insane reason, they thought the risk of travel to a far and distant shore (one they never saw on a google search) with the hope of providing a better future for their family was worth it. Does that mean that we should abandon our personal ancestry that has delivered us to today? Since that is our source of strength why wouldn’t we want to take the best of our past to forge a new collective future?

In emergency medicine, there is also a shining city on the hill. That future involves our patients being seen immediately by an exceptional provider who has immediate access to past medical information. The patient is treated compassionately and efficiently using the latest advances in technology while results are explained in ways they can understand. Once our patients are treated, rapid follow-up is scheduled when necessary to avoid a revisit to the ER and allow other non-urgent conditions to be fully evaluated.

Crazy talk! That’ll never happen! I submit it already does. Look up, over there, up higher. All it takes is for us all to be persistent enough to find the path that gets us there.

May it be a great decade for all of us.

Angelo Falcone, MD

A blueprint for government to positively change healthcare

How the Senate bill would contain the cost of health care: newyorker.com.

A fascinating comparison of health care reform and the transformation of agriculture in America at the turn of the century. Yes government can work when the intent is to gradually change the status quo by small demonstration projects over time leading to radical change on a large scale.

Interview Season in Emergency Medicine

There is a season for everything in life. As well as being the holiday season now is the peak of interview season in medicine. It is the time when many young and well trained residents set out in the world looking for that one elusive goal; the perfect job. Of course everyone knows there is no “perfect job” as what is perfect for one person is a terrible job choice for another. It all depends on what you seek. Is the job in medicine to be academic or community? Do you want to practice in an underserved area, urban or suburban setting? Is your wish to move back home to be close to family or set off and see the world?

The great thing about being in emergency medicine is that the skills and talents you possess are in demand just about wherever you go. I have had the opportunity to give a lecture on searching for the right job to several residency programs. What I try to stress is more than the salary you are offered (okay that’s probably #1 or 2 after your several years of indentured servitude and mountain of debt you’ve accumulated) is the dynamics and culture of the group you will join. Is this a group that seems happy? Considering you are planning to spend the better part of your waking hours with this group of individuals you might at least want to make sure they like one another. Secondly is this a place where you can see yourself in 5 years? Is there opportunity for advancement or potential for finding a “niche” for yourself? I love being a clinician and mixing it up over time is probably the best way to maintain longevity in emergency medicine. Whether that niche be EMS, research, public policy, pediatrics, ultrasound, hyperbarics or leadership it will serve you well to explore the potential as you interview.

Another important aspect of emergency medicine is where it stands in the hospital “food chain”. Is the ED a poor stepchild getting the castoffs from other departments? Look around and you will see during an interview where the department stands. Besides the physical plant, which says a lot in itself, look at the technology in the department. Is there a sono machine that the ED uses for bedside studies? Are there enough computer stations or are you jockeying with the private medical staff for space? Does the difficult airway cart rest in a single laryngoscope blade or is there an assortment of LMAs and fiberoptic laryngoscopes at your disposal? No department is perfect and most are underbedded but is there an acknowledgment by hospital leadership that the ED is indeed the front door to the hospital and there is an attempt to make it a good first impression?

Finally I would ask about what feedback mechanisms are in place and how success is to be measured. How many patients per hour to see or RVUs per hour am I expected to generate? Granted this is very dependent on the acuity of the department but at most places if you can comfortably treat, on average, over 2 patients per hour you should be fine. When you are expected to see over 3 patients per hour, in a high acuity facility, without an assistant or scribe then I would be very skeptical of the position. Ask about the form of feedback. Besides the typical as your Director catches you coming in for your shift “Uh Ang I want to talk with you about the patient you saw last night”. Never a good way to start a shift! Will you have access to personal data and productivity on a regular basis? Will I have an opportunity to sit down and measure my progress with someone to help me improve?

There are so many jobs and so many things that can be hidden from an interview. Be honest with the person with whom you are interviewing and expect them to be honest with you about problems in their department. As Ronald Reagan is famous for saying “trust but verify”. Ask what is the biggest problem currently and what is the plan to fix it. Every department has issues. The key is there a plan on making the situation better and improving the level of care provided to their patients.

Good luck and have fun! It is a great time to be searching for a job in emergency medicine.

Angelo Falcone, MD

Happy Thanksgiving to all those in Emergency Medicine

This message was sent out to members of Medical Emergency Professionals (MEP). It is a reminder that there are many good people working tirelessly in health care. As we give thanks for our many blessings may your Thanksgiving be a joyous and safe one.

On Thursday many of us will sit around a table with family or close friends and give thanks. Some of us will be working, doing what members of MEP and selected professions do, taking care of people. In many ways it is a privilege to be working when every one else is hunkering down to enjoy a perfectly prepared turkey with all the fixings. It’s a reminder to me of the uniqueness of what we do every hour of every day. It is our role in medicine to watch over the communities we serve. In some small ways we are the guardians and I prefer to think of us in such a noble role.

We are the Marines of the medical profession. We are the first line of defense of health care. We are ready at a moments notice to respond to the call. Many times the job is less than glamorous. There is not much thrill in draining an abscess (well maybe some) or in caring for your umpteenth case of non-cardiac chest pain. However for that patient who couldn’t find a PCP to take care of his MRSA abscess or the woman who’s Mom died of an MI in her forties we provide care and comfort.

So in the midst of the debate of how to cover the 40 plus million citizens in this country currently uninsured I give thanks to you. Every day you are there picking up a chart, walking into a room and introducing yourself to the next patient with a simple question. “How can I help you today?” That is a powerful statement about the difference between emergency medicine and the rest of the medical profession. Regardless of social class or insurance status we are here to care for you.

At times it is easy to become insensitive to patients who at times are less than thankful for the care they receive. That is an easy and slippery slope to move towards. I prefer to remember and talk about the thank yous that I, as well as many of you, have received over the years for the care we provide. Thank you for standing beside me and helping to care for that next patient.

And by the way who’s bringing the cranberry sauce tomorrow?

Be well,

Angelo Falcone, MD

Planning for our Future in Medicine

“Man makes plans and God laughs”

This past week our physician group did what many companies do once a year, strategic planning. The format is pretty standard. Pick a place away from your usual site for business, gather together the leadership of your organization, develop priorities on how to make your company better and make a plan to deliver on critical results. We’ve been doing this for the last 9 years in some form or fashion. The success of these endeavors is in not where you start but where you end up. The conversations are open and, occasionally, heated. The intent is to engage the combined intellect of the group to end up in a better place than any one person could forsee or plan to achieve.

For the most part that is what occurs. As I reflect on this past week my mind is drawn to recent debates on the changes afoot in health care and how it will impact health care delivery in the future. Of course, I am also thinking about the movie “2012” and how we might not be around in 3 years to worry about anything. I hope that is not the case but you never know. Back to strategic planning. So, why should anyone take the time to plan?  That’s a good question and one I have thought about seriously over the last few years. Many events are out of our control; weather, acts of God, an unexpected illness or injury and any myriad of bad (and good) things that occur in our individual lives. If you live long enough you know of what I speak. The reason we have decided to plan is that if we are going to hope for a future, it might have a slightly higher chance of occurring if we actually worked for that future to occur.

So we set our priorities for the year and ask what we need to do to achieve these goals. Somewhere in the process of what we discuss and lay out in our plans there is an acknowledgment of the role each of us plays in that future. As we have our discussions we become engaged and energized that the possibility exists to achieve that for which we plan. In medicine so many people believe things are too far out of our control. Blame the insurance companies, the tort climate, the uninsured patients or the government. That is an easy trap in which many people fall. I prefer to believe that the future belongs to those who plan with good intentions and work hard to achieve it.

One of my favorite quotes is:

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Margaret Mead

But I like this one even better:

“I have never been especially impressed by the heroics of people who are convinced they are about to change the world. I am more awed by those who struggle to make one small difference after another.”
Ellen Goodman

So in this time of high rhetoric about the end of days (2012) or the end of health care as we know it, I have chosen to take some time to plan. I look forward to a future in which I will make a small difference. I have chosen to help people with whom I have the privilege to be associated plan for our future together. That future is yet to be determined. Events will unfold before us that will alter our course. Through all of the rises and falls may we continue to endeavor for that future we envision to occur. As we look forward to it may it be so with optimism and hope for a better tomorrow.

Science vs. the Art of Medicine and the use of Medical Scribes

Are we losing the art of medicine as science advances? That is an interesting question. One of the challenges we constantly face in delivering clinically compassionate care is to continue to insure that appropriately skilled people are performing critical jobs. Just as important is to continue remove the non – essential tasks from those critical individuals so they may focus on the patients we serve. Some people use different business processes such as Six Sigma or LEAN to constantly evaluate job functions and make them more efficient. Reducing wasted effort and steps is hailed as the key to making the difference in efficiently (and profitably) delivering a product or service in the marketplace.

I am part of a CEO group thorough my membership in Vistage. It is a group of business CEOs from disparate industries who meet once a month to discuss business challenges and share ideas on how to improve our businesses and live more productive lives. My group is always amused when I tell them the more technology we add to medicine, in the form of EMRs (electronic medical records), the more Inefficient I have become as the provider. I am reduced to a computer data entry operator as I input clinical information or search for patient results from lab and x-ray so I can make decisions on patient dispositions. This occurs while patients continue to stack up and wait for me, and my fellow providers, to continue to receive care. The same can be said for the nursing staff as they have become computer “slaves” tied to the COWS (computers on wheels) to input more and more data, which takes them further and further away from direct patient care.

Of course the march of technology will continue and it has led to stunning advancements in medicine as well as hospital productivity. Numerous examples exist such as digitized radiology systems and electronic medical records available at the touch of a button. The ability for me to perform a simple bedside exam with a portable sonogram machine to diagnose a rupturing abdominal aortic aneurysm was unheard of 10 years ago and does dramatically impact patient care. There is a constant balancing of the “art” and “science” of medicine.

The solution in this high tech world – add more people to the equation! I know it makes no sense that the more technology we infuse the more people we need to carry out some tasks but for our group it does makes sense. Over the last several months we have begun the use of medical “scribes” at Washington County Hospital in Hagerstown, MD. Scribes are individuals who are attached to the doctor’s hip and record the patient encounter, enter the information into the computer, search and track results and alert me when all the information has returned so that I may make a final disposition on a patient.

In my personal experience it has made me 20-25% more efficient (as measure by patients I treat per hour) then before I had a scribe. This is also the typical increase (20%) in productivity that has been seen by Scribe America. (MEP has engaged Scribe America to provide service in all of our locations.) Scribes are not for everyone and I can’t help but think that they will be a viable solution to groups that are searching to improve provider productivity. This is especially true when you are faced with the additional challenges of being unable to add more staffing due to recruitment challenges or financial considerations.

One of the most unexpected benefits of a scribe, for me, has been the ability to be completely focused on the patient during my history and physical exam. I do not need to constantly change the focus from the patient to the piece of paper on my lap to furiously write down all the essential documentation elements so the chart can be appropriately coded, and I can be appropriately paid, for the work I do. I can sit next to the patient and just talk for an uninterrupted few minutes while we have a conversation about why they are here. Perhaps some of the art of medicine may be re-found because of the person sitting over my shoulder or across the bed capturing the critical elements of the patient – doctor exchange.

The art versus science is an interesting contrast. Sometimes it is at odds and often competing for resources in our world of health care. I don’t know the answer but what I do know is that we are going to have to explore new efficient ways to provide care while simultaneously finding way to improve the human component of how that care is delivered. As the use of technology expands and becomes yet more integrated into the patient experience those most successful will be the individuals and organizations who learn how to elevate the human element while the march of new technology continues in the background of the care we provide.