Archive for September, 2014

New Pneumonia Vaccine Guidelines for Patients Over 65

Wednesday, September 24, 2014 // Uncategorized

Recommendations issued on pneumococcal vaccine in elderly patients

These recommendations have been in the works for a long time.  What the CDC didn’t mention is that Medicare hasn’t decided whether to pay for the PCV13 vaccine or not.  Patients anxious to get the vaccine are getting confusing information from pharmacies.  Some are trying to give them the PPSV23 when the ask for the PCV13 which goes by the brand name Prevnar. Until the dust settles, I’m not ordering any.


The Advisory Committee on Immunization Practices (ACIP) recommends that the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) should be routinely administered in series to all adults who are at least 65 years of age, the CDC announced last week.

Adults in this age group who have not previously received a pneumococcal vaccine or who do not know their vaccination history should receive a dose of PCV13, followed by a dose of PPSV23 6 to 12 months later. The 2 vaccines should not be administered together, and the minimum acceptable interval between them is 8 weeks, the ACIP said.

Adults in this age group who have previously received 1 or more doses of PPSV23 should receive a dose of PCV13 if they not already done so. This dose should be given at least 1 year after the most recent PPSV23 dose was received. Patients in whom another dose of PPSV23 is indicated should receive it 6 to 12 months after PCV13 and 5 or more years after the most recent dose of PPSV23.

The recommendations were published in the Sept. 19 Morbidity and Mortality Weekly Report (MMWR).

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Saturday, September 13, 2014 // Uncategorized


A primary care reflects on the shortcomings of medical care in this country and reflects on his encounter with the cardiologist who wrote of his burn out, Dr. Sandeep Jauhar.

Why Your Doctor Doesn’t Listen to You


Daniela Drake  |  September 11, 2014

Victoria* was a teenager when a car struck and almost killed her. A major surgery requiring plastic mesh sewn into her belly saved her life. Soon after, her skin erupted in painful rashes that refused to heal.She consulted specialists all over the country, but they couldn’t help her.  They told her they didn’t know the cause of her rashes, but there was no evidence for rashes related to implants. At one point they even told her she was delusional, despite her diffuse ulcerating lesions. After a decade of searching, Victoria found a physician who’d seen patients with unusual symptoms under similar circumstances. After he removed the plastic implant, her skin cleared up completely.

As Victoria spoke, my heart broke as it does every time I hear stories of patient neglect. The week before, a young man named Jack* told a similar story: an accident, then an illness followed by years of debilitating symptoms that forced him to travel the country consulting specialists looking for an answer that never came—until he found a doctor who listened and she began to work with him to find a way to heal.

These stories will come as no surprise to anyone with a chronic illness. All too often, we conventional physicians dismiss patients with unusual complaints or simply ply them with medicines. Of course, the medical community can’t develop a new “evidence base” if we ignore our patients. It’s an insane medical Catch-22, and patients are getting fed up. Now, instead of turning to the once trusted physician, many Americans are spending billions onalternative and complementary medicine.

Is the medicine we practice simply no good, or are the doctors to blame? The answer might be both.

It’s widely accepted that conventional medicine frequently fails to help people with chronic ailments. It’s set up to fail, as most clinics function as dehumanizing assembly lines better suited for manufacturing cars than treating people. While health care consultants insist on finding ways to enhance “efficiency,” efficiency and assembly lines only make sense if we know everything there is to know about how the body functions—but we don’t.

It’s a well-known fact that many patients don’t fit our heuristics. Instead, they have weird, unrecognizable constellations of symptoms—and most doctors don’t have the time to deal with it. If we do anything for them at all, we might scan or scope them, send them for referrals, and then finally send them away with a printout explaining fibromyalgia or irritable bowel syndrome or other similar diagnoses. Doctors are then on to the next patient, and between patients they are distracted by a towering mountain of non-clinical tasks. Doctors aren’t dumb. They know this is a rotten deal and they are demoralized, running faster and faster with no hope of catching up.

Now The New York Times best-selling book Doctored, The Disillusionment of the American Physician, by Sandeep Jauhar, MD, explores this dismal state of affairs. The book is a memoir that highlights the problem of physician burnout in the midst of our by now decades-long health care crisis. In a recent Wall Street Journalfeature, Jauhar neatly details how we got here—how corporate and government intrusions turned a once intellectually stimulating profession into a mind-numbing enterprise. One physician who commented on Jauhar’s article even likened it to slavery. In another recentMedscape article, one physician described himself as a “beaten dog.”

If doctoring these days is akin to a kind of humiliated servitude—and many physicians in their private momentsclaim that it is—then it’s axiomatic that we need less centralized control and more freedom in order to be more responsive to patients. But Dr. Jauhar, who is a cardiologist and director of the Heart Failure Program at Long Island Jewish Medical Center, seemed to be calling for more centralized control and something he calls “bundled payments” to control costs, akin to the ill-conceived Accountable Care Organizations that many people justifiably believe are doomed to fail.

Many doctors were disappointed—including me. Jauhar is clearly an intelligent doctor and writer who has garnered the attention of important decision-makers. He was putting a spotlight on a problem that needs addressing badly, and yet he seemed to be summoning up the same tired solution we’ve already been trying for 30 years. I concluded that Jauhar had to be another out-of-touch East Coast academic physician.

But I was wrong. When we spoke, I found Dr. Jauhar to be a deeply thoughtful physician whose experiences were remarkably similar to mine, even though we practice on opposite sides of the country. “The last thing I intended was to call for more bureaucratic entanglements or more regulations,” Jauhar said. “I am also a practicing physician and I deal with this stuff all the time.”

During the course of our conversation, Jauhar spoke about doctors burdened with unnecessary paperwork and how it takes away from patient care. In one amusing coincidence, we had both recently been tasked to write a letter attesting to a patient’s need for oxygen. For both of us, it took several iterations—requiring rewrites and multiple faxes— to get the wording precisely right for the oxygen to be delivered. The medical equipment companies, under increased scrutiny of the Affordable Care Act, insist on elaborate documentation to protect themselves in the case of an insurance or Medicare audit.

I point out this trivial example exactlybecause it is trivial—and it was common to both of us, although Jauhar is a specialist and I am a primary care physician. This is a reckless misuse of physician time and energy. A country that is serious about health reform would not take a limited, valued resource and waste it on nonsense like this. It shouldn’t be a surprise then, when a patient presents with unusual symptoms, the overburdened physician is simply not listening. He may be worried if the fax went through or that a desperate patient can’t get an oxygen tank, and he may give the patient in front of him the usual thoughtless response: “That’s not in the evidence base.”

Physicians are overwhelmed because we are in the middle of a collision of powerful unrestrained forces. In the last 30 years, there’s never been the political will to take on pharmaceutical pricing, exploitative insurance contracting with physicians, tort reform, administration and CEO salaries, payments to home health companies, cost shifting to ERs, the overpricing of imaging services, or patient demands for unnecessary care (a major driver of spending).

Instead of dealing with any of these politically sensitive items, every single one of them has become part of the physician’s to-do list. Overpriced drugs? Make the doctor call in for a “prior authorization.” Concerned about fraud? Make the physician fax over a carefully worded note—three times if necessary. Worried about lack of supervision of physical therapists? Make the doctor sign an illegible six-page treatment plan that he has no expertise in or ability to evaluate. Worried about hospital re-admissions? Dock the physician’s pay. Worried that with all of this stress your doctor may not always be so nice? Arm the patient with a patient-satisfaction scorecard.

To be sure, patients should have some guarantee that when they see a doctor, they will get a basic level of acceptable care—and certainly the instinct to control costs is an honorable one. But does anyone think this litany of tasks is an appropriate use of physician time? If you do, please tell that to the seriously ill woman I met recently who can’t get in to see her doctor until next May.

So, how can we right this ship, given the politically powerful, well-financed parties who are profiting from the way things are now?  “If I am to call for anything, it would be a greater emphasis on professionalism. It would be great if doctors could do it themselves, but it’s very hard to incentivize professionalism,” Dr. Jauhar said. “We need to return to a professional core where we put the patients first.”

I think he’s right. But the patient is not “put first” when it comes to corporate medicine. There are too many patients like Jack and Victoria scrounging around for years until they find a doctor who will listen. Indeed, turning all doctors into employees is quite a dangerous proposition. Doctors will be too busy to do anything but mindlessly write whatever prescriptions they tell us to write—while assuring us that it is “evidence based.” And corporations will squeeze the patient visit more—now they are even promoting the absurd notion of the “group visit” to increase physician “productivity.”

Physicians will regain our professionalism when we stop participating in this circus. For most primary care physicians, that will mean turning to direct pay or concierge medicine—because all this interference with the doctor-patient relationship has ended up putting the patient last.

*Names have been changed.  

Related from The Daily Beast



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Electronic Records Waste Time

Thursday, September 11, 2014 // Uncategorized

Doctors have less time than ever to spend with patients and a lot of that is being squandered on dotting I’s and crossing T’s with the use of new electronic medical records according to this new study.  It sounded like a good idea on the time, but has yet to meet up to expectations.

Doctors Say Electronic Records Waste Time

A new study shows that technology has slowed doctors’ work.


Data entry is eating up roughly four hours a week of your doctor’s time.

By Sept. 8, 2014 | 4:00 p.m. EDT + More
Doctors complain that they waste an average of 48 minutes a day, or four hours a week, when they record their patients’ health information into digital records, a new study shows.

The results were collected in a small survey, whose findings were put into a letter that was published Monday in the online edition of JAMA Internal Medicine. A draft of the letter was released Monday to a group of health care reporters at the National Library of Medicine. Dr. Clement McDonald, lead author of the study and director of the NLM Lister Hill National Center for Biomedical Communications, presented the letter, “The Use of Internist’s Free Time by Ambulatory Care Electronic Medical Record Systems.”

The findings came from a 19-question survey that the American College of Physicians sent in December 2012 to 900 ACP members and 102 non-members. They received a 53.6 percent response rate; respondents had used 61 different EMR systems.

The mean loss for trainees was lower than the average, at 18 minutes a day. “We can only speculate as to whether better computer skills, shorter (half-day) clinic assignments with proportionately less exposure to EMR time costs, or other factors account for the trainees’ smaller per-day time loss,” the study read.

Time taken to fill out records at the Veteran’s Affairs department was also less, even though the agency has come under criticism as military and veteran patients died while waiting to be seen by health care providers. The agency’s Computer Patient Record System was associated with the least amount of time lost, an average of 20 minutes a day. McDonald says part of the reason for this is that the agency adopted the technology much earlier than the rest of the health care industry.

Hospitals, clinics and individual providers have moved more slowly toward digital use than other industries, such as banking or shopping. President Barack Obama championed electronic health care records during his first presidential campaign, then pushed their implementation to lay the groundwork for the nation’s health care reform package.

To encourage adoption of the technology, doctors and hospitals were given $27 billion in the 2008 economic stimulus, a flood of money the government tried to use to jump-start the economy during the Great Recession.

The money, distributed by the Centers for Medicare and Medicaid Services, was intended to encourage health care organizations to adopt electronic records, and penalize them through lower Medicare or Medicaid reimbursements if they did not comply. The law requires health care providers to demonstrate not only that they are using electronic health records, but that those records meet requirements outlined by the government.

Health care providers are using iPads more frequently, and some have taken on Google Glasses. McDonald says he would like to see health care providers record patient visits, so they can take their diagnosis home to go over it with family members, when they are not overwhelmed in a doctor’s office or hospital with the information they have just been given.

There still are numerous disconnects for implementation, however. Different digital record systems do not work with each other, for example, and doctors can miss visual cues when they are looking at a computer instead of at a patient. Some patients do not understand the systems and think doctors are checking their email during an appointment.

To avoid this, some doctors will talk to patients while scribes type information into a computer, but that is less cost-effective. “Humans like to do things quickly and efficiently,” McDonald says. “You can’t always do something magically faster with technology.”

Proponents of electronic health records say they have the potential to reduce medical errors, better coordinate care, and save time. Some say the technology, however, hasn’t reached that point. “It simply takes longer [to enter patient information into a computer],” says McDonald, who is a proponent of EHRs and was among a group which created the first system in the country. “There is already so much to do and you have to look at patient safety.” Deep consequences can come out of one typo, he adds, and adding another data point carries additional time cost.

McDonald expected the results from the study because he has heard complaints from doctors who said they were spending extra time with EHRs after work, he says.

The time lost, the letter points out, could decrease access to care, given the opportunity cost of meeting with a patient during that time. It also could increase the cost of care. “Policy makers should consider these time costs in future EHR mandates,” McDonald says.

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Sick Doctors

Thursday, September 4, 2014 // Uncategorized



This is an essay by a doctor which accurately outlines the reasons for physician dissatisfaction.  He twists off a little at the end when he discusses his solutions.  He says that physicians should be paid for performance ignoring the studies that show that this has not resulted in long term improvement in patient care.  He talks about bundled payments to physicians.  The implication is that all physicians need to be in large groups.  This has not been shown to lead to improvement in patient care.  In fact, a recent study shows that smaller practices have lower hospital readmission rates which is felt by some  to be an indicator of quality.  He says that physicians should not be paid per encounter.  I agree.  Primary care physicians should be paid for taking care of patients, managing their care.  That is what we do.

The Saturday Essay

Why Doctors Are Sick of Their Profession

American physicians are increasingly unhappy with their once-vaunted profession, and that malaise is bad for their patients


Sandeep Jauhar

Aug. 29, 2014 11:16 a.m. ET

What happens when doctors are unhappy? They have unhappy patients. A new memoir, ‘Doctored,’ presents one cardiologist’s take on the challenges facing American medicine and the real impact on patient care. Dr. Sandeep Jauhar discusses his book on Lunch Break with Tanya Rivero. Photo: Getty

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals.

It could be just a midlife crisis, but it occurs to me that my profession is in a sort of midlife crisis of its own. In the past four decades, American doctors have lost the status they used to enjoy. In the mid-20th century, physicians were the pillars of any community. If you were smart and sincere and ambitious, at the top of your class, there was nothing nobler or more rewarding that you could aspire to become.

Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of 12,000 physicians, only 6% described their morale as positive. Eighty-four percent said that their incomes were constant or decreasing. Most said they didn’t have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether.

American doctors are suffering from a collective malaise. We strove, made sacrifices—and for what? For many of us, the job has become only that—a job.

That attitude isn’t just a problem for doctors. It hurts patients too.

In a survey of 12,000 physicians, only 6% described their morale as positive. Getty Images

Consider what one doctor had to say on Sermo, the online community of more than 270,000 physicians:

“I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotguning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a moneymaking game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.”

The discontent is alarming, but how did we get to this point? To some degree, doctors themselves are at fault.

In the halcyon days of the mid-20th century, American medicine was also in a golden age. Life expectancy increased sharply (from 65 years in 1940 to 71 years in 1970), aided by such triumphs of medical science as polio vaccination and heart-lung bypass. Doctors largely set their own hours and determined their own fees. Popular depictions of physicians (“Marcus Welby,” “General Hospital”) were overwhelmingly positive, almost heroic.

American doctors at midcentury were generally content with their circumstances. They were prospering under the private fee-for-service model, in which patients were covering costs out of pocket or through fledgling private insurance programs such as Blue Cross/Blue Shield. They could regulate fees based on a patient’s ability to pay and look like benefactors. They weren’t subordinated to bureaucratic hierarchy.


After Medicare was introduced in 1965 as a social safety net for the elderly, doctors’ salaries actually increased as more people sought medical care. In 1940, in inflation-adjusted 2010 dollars, the mean income for U.S. physicians was about $50,000. By 1970, it was close to $250,000—nearly six times the median household income.

But as doctors profited, they were increasingly perceived as bilking the system. Year after year, health-care spending grew faster than the U.S. economy as a whole. Meanwhile, reports of waste and fraud were rampant. A congressional investigation found that in 1974, surgeons performed 2.4 million unnecessary operations, costing nearly $4 billion and resulting in nearly 12,000 deaths. In 1969, the president of the New Haven County Medical Society warned his colleagues “to quit strangling the goose that can lay those golden eggs.”

If doctors were mismanaging their patients’ care, someone else would have to manage that care for them. Beginning in 1970, health maintenance organizations, or HMOs, were championed to promote a new kind of health-care delivery built around price controls and fixed payments. Unlike with Medicare or private insurance, doctors themselves would be held responsible for excess spending. Other novel mechanisms were introduced to curtail health outlays, including greater cost-sharing by patients and insurer reviews of the necessity of medical services. That ushered in the era of HMOs.

In 1973, fewer than 15% of physicians reported any doubts that they had made the right career choice. By 1981, half said they would not recommend the practice of medicine as highly as they would have a decade earlier.

Public opinion of doctors shifted distinctly downward too. Doctors were no longer unquestioningly exalted. On television, physicians were portrayed as more human—flawed or vulnerable (“M*A*S*H*,” “St. Elsewhere”) or professionally and personally fallible (“ER”).

As managed care grew (by the early 2000s, 95% of insured workers were in some sort of managed-care plan), physicians’ confidence plummeted. In 2001, 58% of about 2,000 physicians questioned said that their enthusiasm for medicine had gone down in the previous five years, and 87% said that their overall morale had declined during that time. More recent surveys have shown that 30% to 40% of practicing physicians wouldn’t choose to enter the medical profession if they were deciding on a career again—and an even higher percentage wouldn’t encourage their children to pursue a medical career.

There are many reasons for this disillusionment besides managed care. One unintended consequence of progress is that physicians increasingly say they don’t have enough time to spend with patients. Medical advances have transformed once-terminal diseases—cancer, AIDS, congestive heart failure—into complex chronic conditions that must be managed over the long term. Physicians also have more diagnostic and treatment options and must provide a growing array of screenings and other preventative services.

At the same time, salaries haven’t kept pace with doctors’ expectations. In 1970, the average inflation-adjusted income of general practitioners was $185,000. In 2010, it was $161,000, despite a near doubling of the number of patients that doctors see a day.

While patients today are undoubtedly paying more for medical care, less of that money is actually going to the people who provide the care. According to a 2002 article in the journal Academic Medicine, the return on educational investment for primary-care physicians, adjusted for differences in number of hours worked, is just under $6 per hour, as compared with $11 for lawyers. Some doctors are limiting their practices to patients who can pay out of pocket without insurance company discounting.

Other factors in our profession’s woes include a labyrinthine payer bureaucracy. U.S. doctors spend almost an hour on average each day, and $83,000 a year—four times their Canadian counterparts—dealing with the paperwork of insurance companies. Their office staffs spend more than seven hours a day. And don’t forget the fear of lawsuits; runaway malpractice-liability premiums; and finally the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government.

The growing discontent has serious consequences for patients. One is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners. Try getting a timely appointment with your family doctor; in some parts of the country, it is next to impossible. Aging baby boomers are starting to require more care just as aging baby boomer physicians are getting ready to retire. The country is going to need new doctors, especially geriatricians and other primary care physicians, to care for these patients. But interest in primary care is at an all-time low.

Perhaps the most serious downside, however, is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. People used to talk about “my doctor.” Now, in a given year, Medicare patients see on average two different primary care physicians and five specialists working in four separate practices. For many of us, it is rare to find a primary physician who can remember us from visit to visit, let alone come to know us in depth or with any meaning or relevancy.

Insensitivity in patient-doctor interactions has become almost normal. I once took care of a patient who developed kidney failure after receiving contrast dye for a CT scan. On rounds, he recalled for me a conversation he’d had with his nephrologist about whether his kidney function was going to get better. “The doctor said, ‘What do you mean?’ ” my patient told me. “I said, ‘Are my kidneys going to come back?’ He said, ‘How long have you been on dialysis?’ I said, ‘A few days.’ And then he thought for a moment and said, ‘Nah, I don’t think they’re going to come back.’ ”

My patient broke into sobs. ” ‘Nah, I don’t think they’re going to come back.’ That’s what he said to me. Just like that.”

Of course, doctors aren’t the only professionals who are unhappy today. Many professions, including law and teaching, have become constrained by corporate structures, resulting in loss of autonomy, status, and respect. But as the Princeton sociologist Paul Starr writes, for most of the 20th century, medicine was “the heroic exception that sustained the waning tradition of independent professionalism.” It is an exception whose time has expired.

How can we reverse the disillusionment that is so widespread in the medical profession? There are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.

The challenge in dealing with physician burnout on a practical level is to create new incentive schemes to foster that meaning: publicizing clinical excellence, for example (public reporting of surgeons’ mortality rates or physicians’ readmission rates is a good first step), or giving rewards for patient satisfaction (physicians at my hospital now receive quarterly reports that tell us how our patients rate us on measures such as communication skills and the amount of time we spend with them).

We also need to replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves, or pay for performance, which offers incentives for good health outcomes. We need systems that don’t simply reward high-volume care but also help restore the humanism in doctor-patient relationships that have been weakened by business considerations, corporate directives and third-party intrusions.

I believe most doctors continue to want to be like the physician knights of the golden age of medicine. Most of us went into medicine to help people. We want to practice medicine the right way, but too many forces today are propelling us away from the bench or the bedside. No one ever goes into medicine to do unnecessary testing, but this sort of behavior is rampant. The American system too often seems to promote knavery over knighthood.

Fulfillment in medicine, as with any endeavor, is about managing hopes. Probably the group best equipped to deal with the changes wracking the profession today is medical students, who are not so weighed down by great expectations. Doctors ensconced in professional midlife are having the hardest time.

In the end, the problem is one of resilience. American doctors need an internal compass to navigate the changing landscape of our profession. For most doctors, this compass begins and ends with their patients. In surveys, most physicians—even the dissatisfied ones—say the best part of their jobs is taking care of people. I believe this is the key to coping with the stresses of contemporary medicine: identifying what is important to you, what you believe in and what you will fight for. Medical schools and residency programs can help by instilling professionalism early on and assessing it frequently throughout the many years of training. Introducing students to virtuous mentors and alternative career options, such as part-time work, may also help stem some of the burnout.

What’s most important to me as a doctor, I’ve learned, are the human moments. Medicine is about taking care of people in their most vulnerable states and making yourself somewhat vulnerable in the process. Those human moments are what others—the lawyers, the bankers—envy about our profession, and no company, no agency, no entity can take those away. Ultimately, this is the best hope for our professional salvation.

Dr. Jauhar is director of the Heart Failure Program at the Long Island Jewish Medical Center. This essay is adapted from his new book, “Doctored: The Disillusionment of an American Physician,” published by Farrar, Straus and Giroux.

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