So happy New Year! We have started the year with health care costs that have risen only as fast as the GDP. We can do better, yes, but it is clear that better is the direction in which we are moving.
Saturday, January 14, 2012
Good news about health care costs!
So happy New Year! We have started the year with health care costs that have risen only as fast as the GDP. We can do better, yes, but it is clear that better is the direction in which we are moving.
Is Pradaxa (dabigatran) dangerous? Comparing Pradaxa, Xarelto and warfarin
Just today while poking through studies recently released, I came upon an article that added to my growing discomfort with using Pradaxa, an anticoagulant ("blood thinner") that is now being widely used as an alternative for warfarin (coumadin is the brand name) for people with atrial fibrillation in order to reduce their risk for stroke.
Atrial fibrillation is a condition in which the atrium (entry chamber) of the heart wiggles rather than beats, and is caused by high blood pressure, valve problems, alcohol abuse and a number of other factors. The wiggling rather than beating atrium can build up blood clots which can migrate into arteries all over the body, but most devastatingly in the brain to cause strokes. Taking an anticoagulant reduces this risk. But blood has a very good reason for clotting, and when it is inhibited from clotting, a person can bleed, sometimes catastrophically, from an injury or an ulcer or a weak area in the tissues of the body. Like the use of any drug, anticoagulant use involves considering whether risks are less than expected benefits. Warfarin, our old standard drug, required that we monitor the level of anticoagulation with a blood test about every month. This was annoying and resource consuming, but had the effect of keeping us in contact with our patients and of making them realize, monthly, that there was risk associated with taking the drug. It was not uncommon for the level to drop too low to be protective, or to rise to the point that serious bleeding could occur. Still, most patients did fine. The drug became generic a few years ago so its cost was not too significant, and insurance covered the blood tests and followup.
Pradaxa, on the other hand, requires no monitoring. It is dosed twice daily rather than once, as for warfarin, but it is great to not have to worry about monthly visits. Warfarin blocked the action of vitamin K, so could be reversed by eating foods with lots of vitamin K, so patients had to be careful with their diets. Pradaxa has no such restrictions. Because Warfarin blocked vitamin K as its main mechanism of action, giving high doses of vitamin K was pretty effective in stopping bleeding if a person was injured or needed surgery, and if we needed to reverse it even more quickly we could use blood plasma. In the case of Pradaxa, though, there is no known agent that reverses its effects, though its effects do fade in about 24 hours. Unlike warfarin which takes days to become effective, pradaxa works in less than an hour, which in some situations might be life saving.
I was a great fan of Pradaxa when it first came out because my patients really did hate to get regular blood tests with warfarin and sometimes their doses were very difficult to stabilize. I saw many bleeding complications over the years that I practiced with warfarin, and occasionally strokes when the dose was too low. I woke up to problems with Pradaxa when I went to an Advanced Trauma Life Support course and found that the surgeons who dealt with patients who are injured were very opposed to anticoagulants, especially ones that couldn't be reversed. Patients who had trauma to their heads or abdomens and were on such drugs would bleed and die and the surgeon would have to sit by and watch. The surgeons asked why internists like myself would push so strongly to get patients to take these drugs to reduce risk of stroke, when the patient might just as easily die of bleeding should they fall or be in a car accident.
The article that just came out was in the Archives of Internal Medicine this month and showed that patients who took Pradaxa were 1.33 times as likely as patients who took no anticoagulants, aspirin or warfarin to had heart attacks or near heart attacks. I have no real idea why this would be, but the study was large and performed at several centers, so apparently something about this drug may make microclots in the coronary arteries occur or make platelets more sticky. In any case, it sure makes me think twice about using it.
Just very recently another drug like Pradaxa was released for use, and it may be better. The brand name is Xarelto, generic name Rivaroxaban. This drug is dosed once daily and can be reversed with a blood product called prothrombin complex. Its official indications are broader than Pradaxa. It can be used both for atrial fibrillation and preventing blood clots in the legs of patients who have had hip or knee replacements. It's likely that both Pradaxa and Xarelto are good for any clotting condition, but the FDA is slow to expand its recommendations due to the fact that blood clotting conditions are very risky, and there are other drugs that have long histories of effectiveness.
The cost of these new anticoagulants is really steep. Drugstore.com quotes a price of $245 for a month's supply of Pradaxa, and looking at sources online for Xarelto, costs for that will be really similar. Warfarin only costs about 15 dollars a month, but monitoring and complications bring the cost up significantly in the big picture. Both of the new drugs are less likely to cause fatal bleeding than warfarin.
So the answer to the question "is Pradaxa dangerous?" is "of course!" which also is true of Xarelto and warfarin.
Atrial fibrillation is a condition in which the atrium (entry chamber) of the heart wiggles rather than beats, and is caused by high blood pressure, valve problems, alcohol abuse and a number of other factors. The wiggling rather than beating atrium can build up blood clots which can migrate into arteries all over the body, but most devastatingly in the brain to cause strokes. Taking an anticoagulant reduces this risk. But blood has a very good reason for clotting, and when it is inhibited from clotting, a person can bleed, sometimes catastrophically, from an injury or an ulcer or a weak area in the tissues of the body. Like the use of any drug, anticoagulant use involves considering whether risks are less than expected benefits. Warfarin, our old standard drug, required that we monitor the level of anticoagulation with a blood test about every month. This was annoying and resource consuming, but had the effect of keeping us in contact with our patients and of making them realize, monthly, that there was risk associated with taking the drug. It was not uncommon for the level to drop too low to be protective, or to rise to the point that serious bleeding could occur. Still, most patients did fine. The drug became generic a few years ago so its cost was not too significant, and insurance covered the blood tests and followup.
Pradaxa, on the other hand, requires no monitoring. It is dosed twice daily rather than once, as for warfarin, but it is great to not have to worry about monthly visits. Warfarin blocked the action of vitamin K, so could be reversed by eating foods with lots of vitamin K, so patients had to be careful with their diets. Pradaxa has no such restrictions. Because Warfarin blocked vitamin K as its main mechanism of action, giving high doses of vitamin K was pretty effective in stopping bleeding if a person was injured or needed surgery, and if we needed to reverse it even more quickly we could use blood plasma. In the case of Pradaxa, though, there is no known agent that reverses its effects, though its effects do fade in about 24 hours. Unlike warfarin which takes days to become effective, pradaxa works in less than an hour, which in some situations might be life saving.
I was a great fan of Pradaxa when it first came out because my patients really did hate to get regular blood tests with warfarin and sometimes their doses were very difficult to stabilize. I saw many bleeding complications over the years that I practiced with warfarin, and occasionally strokes when the dose was too low. I woke up to problems with Pradaxa when I went to an Advanced Trauma Life Support course and found that the surgeons who dealt with patients who are injured were very opposed to anticoagulants, especially ones that couldn't be reversed. Patients who had trauma to their heads or abdomens and were on such drugs would bleed and die and the surgeon would have to sit by and watch. The surgeons asked why internists like myself would push so strongly to get patients to take these drugs to reduce risk of stroke, when the patient might just as easily die of bleeding should they fall or be in a car accident.
The article that just came out was in the Archives of Internal Medicine this month and showed that patients who took Pradaxa were 1.33 times as likely as patients who took no anticoagulants, aspirin or warfarin to had heart attacks or near heart attacks. I have no real idea why this would be, but the study was large and performed at several centers, so apparently something about this drug may make microclots in the coronary arteries occur or make platelets more sticky. In any case, it sure makes me think twice about using it.
Just very recently another drug like Pradaxa was released for use, and it may be better. The brand name is Xarelto, generic name Rivaroxaban. This drug is dosed once daily and can be reversed with a blood product called prothrombin complex. Its official indications are broader than Pradaxa. It can be used both for atrial fibrillation and preventing blood clots in the legs of patients who have had hip or knee replacements. It's likely that both Pradaxa and Xarelto are good for any clotting condition, but the FDA is slow to expand its recommendations due to the fact that blood clotting conditions are very risky, and there are other drugs that have long histories of effectiveness.
The cost of these new anticoagulants is really steep. Drugstore.com quotes a price of $245 for a month's supply of Pradaxa, and looking at sources online for Xarelto, costs for that will be really similar. Warfarin only costs about 15 dollars a month, but monitoring and complications bring the cost up significantly in the big picture. Both of the new drugs are less likely to cause fatal bleeding than warfarin.
So the answer to the question "is Pradaxa dangerous?" is "of course!" which also is true of Xarelto and warfarin.
Thursday, January 12, 2012
Apollo Munich’s Top Up Plan - Optima Plus
A person looking for a health plan would prefer to buy a product that can offer wide coverage along with a long list of benefits. To cater to this need Apollo Munich has formulated the Optima Plus health plan. Whenever there is a need of healthcare, there are various medical and non medical requirements that lead to expenses. Optima Plus is a plan that serves as a complete health coverage plan.
It is a top-up health insurance plan that can be issued to the individual and/or the family. To fulfill the health needs of people at large this plan offers coverage for the expenses of pre and post- hospitalization, in- patient treatment and 140 day care procedures as mentioned in the policy. It also safeguards the insured from the expenses incurred while availing of medical treatment at home under the domiciliary treatment benefit.
In addition Optima Plus offers life-long renewal facility. This enables the person to take the benefit of health coverage for an extended period of time. In this way it becomes a comprehensive health plan. This plan is available at cost effective rates that resolve the affordability issue for people. It is a simple to understand and easy to afford health plan.
Apollo Munich aims at increasing the number of insured in the country. Optima Plus is a plan that contributes greatly to this objective. This is a plan that comes with no maximum cover ceasing age. Also it offers a discount of 7.5% on the premium amount if you choose the policy for a time period of 2 years.
It is a plan that gives an option of waiving the deductible between the age of 58- 60. The deductible is the specific amount that the policy holder is supposed to pay for his/ her health care expenses in case there is a need for hospitalization before any benefit from the policy can be availed. This plan can provide the basic health insurance along with the promise of several other healthcare benefits. The insured can enjoy the wide coverage benefits for a lifetime.
Also it incorporates the easy portability service. It allows the person to avail of the policy by getting transferred from any other policy. Moreover it offers health protection to dependent family members at a reasonable cost. It covers the self, spouse, dependent parents and dependent children under one umbrella. Thus the insured is just required to pay a single premium instead of paying it separately for each member. To make it more beneficial, the insurer offers an added advantage of 10% family discount in case 2 or more family members are included in the plan.
Avail all the mentioned benefits by paying a reasonable insurance cost of Optima Plus.
It is a top-up health insurance plan that can be issued to the individual and/or the family. To fulfill the health needs of people at large this plan offers coverage for the expenses of pre and post- hospitalization, in- patient treatment and 140 day care procedures as mentioned in the policy. It also safeguards the insured from the expenses incurred while availing of medical treatment at home under the domiciliary treatment benefit.
In addition Optima Plus offers life-long renewal facility. This enables the person to take the benefit of health coverage for an extended period of time. In this way it becomes a comprehensive health plan. This plan is available at cost effective rates that resolve the affordability issue for people. It is a simple to understand and easy to afford health plan.
Apollo Munich aims at increasing the number of insured in the country. Optima Plus is a plan that contributes greatly to this objective. This is a plan that comes with no maximum cover ceasing age. Also it offers a discount of 7.5% on the premium amount if you choose the policy for a time period of 2 years.
It is a plan that gives an option of waiving the deductible between the age of 58- 60. The deductible is the specific amount that the policy holder is supposed to pay for his/ her health care expenses in case there is a need for hospitalization before any benefit from the policy can be availed. This plan can provide the basic health insurance along with the promise of several other healthcare benefits. The insured can enjoy the wide coverage benefits for a lifetime.
Also it incorporates the easy portability service. It allows the person to avail of the policy by getting transferred from any other policy. Moreover it offers health protection to dependent family members at a reasonable cost. It covers the self, spouse, dependent parents and dependent children under one umbrella. Thus the insured is just required to pay a single premium instead of paying it separately for each member. To make it more beneficial, the insurer offers an added advantage of 10% family discount in case 2 or more family members are included in the plan.
Avail all the mentioned benefits by paying a reasonable insurance cost of Optima Plus.
Apollo Munich Optima Restore Plan
Optima Restore is a newly launched plan by Apollo Munich. Working with a team of experts, the provider has formulated a plan that is rich with distinctive benefits. This plan incorporates the Restore Benefit that is a unique feature. Under this provision the policy restores the basic sum insured in case one exhausts it within the policy year. This enables the person get covered for any other illness that would otherwise have to be paid for through one’s own pocket, at no extra cost.
Besides this, the policy includes a Multiplier Benefit, which is another amazing feature. It allows the policy holder to get the basic sum insured increased by 50% if he/she has a claim free year. This comes as a no claim bonus, giving a beneficial service to the insured. It gets further extended in next year if the insured still does not apply for claim. In the second year, the policy doubles the sum insured making it 100% of the insurance amount. These two beneficial features make this plan different from various other health coverage plans.
Apollo Munich aims at providing best health care services to people. To fulfill this need it has emerged with several comprehensive health plans. By formulating cost effective policies it enables people of all income groups to avail the best health treatment. Optima restore is one such plan that is enriched with numerous benefits. It is a plan that comes with the facility of lifelong renewal. The insured can stay covered for an extended period of time.
In addition it includes the feature of cashless hospitalization. The policy holder can enjoy the health treatment on cashless basis across 4000 hospitals that come within the empanelled network. It also provides coverage for the pre and post- hospitalization expenses. To join the list there are features like in- patient treatment, coverage for day care procedures and emergency ambulance. This makes it a complete package that can fulfill the basic medical care needs along with the several beneficial services.
Optima Restore is available as an individual coverage plan and also as a floater policy. With all its wide ranging benefits it can cover all the family members. This plan can cater to the health needs of the entire family at the cost of a single affordable premium. The reasonable premium cost makes it a comprehensive health plan. The floater plan includes self, spouse, dependent parents and dependent children. In this way this plan is ready to offer utmost benefits to the individual or family.
Equipped with all such features, Apollo Munich has formulated this plan with various unique and never-before features.
Besides this, the policy includes a Multiplier Benefit, which is another amazing feature. It allows the policy holder to get the basic sum insured increased by 50% if he/she has a claim free year. This comes as a no claim bonus, giving a beneficial service to the insured. It gets further extended in next year if the insured still does not apply for claim. In the second year, the policy doubles the sum insured making it 100% of the insurance amount. These two beneficial features make this plan different from various other health coverage plans.
Apollo Munich aims at providing best health care services to people. To fulfill this need it has emerged with several comprehensive health plans. By formulating cost effective policies it enables people of all income groups to avail the best health treatment. Optima restore is one such plan that is enriched with numerous benefits. It is a plan that comes with the facility of lifelong renewal. The insured can stay covered for an extended period of time.
In addition it includes the feature of cashless hospitalization. The policy holder can enjoy the health treatment on cashless basis across 4000 hospitals that come within the empanelled network. It also provides coverage for the pre and post- hospitalization expenses. To join the list there are features like in- patient treatment, coverage for day care procedures and emergency ambulance. This makes it a complete package that can fulfill the basic medical care needs along with the several beneficial services.
Optima Restore is available as an individual coverage plan and also as a floater policy. With all its wide ranging benefits it can cover all the family members. This plan can cater to the health needs of the entire family at the cost of a single affordable premium. The reasonable premium cost makes it a comprehensive health plan. The floater plan includes self, spouse, dependent parents and dependent children. In this way this plan is ready to offer utmost benefits to the individual or family.
Equipped with all such features, Apollo Munich has formulated this plan with various unique and never-before features.
Wednesday, January 4, 2012
Christian Science, faith healing and mind-body medicine with mention of the work of Elisabeth Fischer Targ MD
Mary Baker Eddy was a "sickly child" who heard voices and was known as someone who could heal sick animals. She remained sick for much of her adult life, even giving up care of her only son due to illness. She believed (and this is based on a pretty cursory look at her book, so take it with a grain of salt) that God and the spirit, love and truth and good, were all the real things of existence, and material things, including the body and matter in general, were false and mostly unimportant. Regarding healing she wrote "When the sick are made to realize the lie of personal sense, the body is healed." She described her religion as "primitive Christianity" and the churches she established were very popular and remain so, to some extent. One of the publications that began with the movement, the Christian Science Monitor, is still very active and an excellent source of non-partisan news.
I am neither a devout Christian nor an integrative medicine specialist or mind-body practitioner, yet I have had a longstanding interest in the power of meditation and focused thought or visualization to heal. Even at Harvard, that bastion of evidence based medicine, we see practitioners looking to find the science behind the success of various relaxations techniques and spiritual practices in curing illness and promoting wellness. A rather funny animal model of meditation (which I heard about at the Mind-body medicine course I just attended last month at Harvard) is allowing rats to shred pieces of compressed fiber to make nests. The happy shredders heal up experimentally inflicted burns much faster than their bored and idle litter mates.
I think that Mary Baker Eddy must have been sick with one of the diseases that is primarily characterized by pain and fatigue, like fibromyalgia, migraine headaches or chronic fatigue syndrome, since she died in her late 80s despite years of being ill in a time when medical care was at best ineffective and at worst toxic. Even now, though we have potions and pills galore for these conditions, most of them work poorly, with high costs and sometimes devastating side effects. I suspect that faith healing was a truly excellent approach for what she had, though it might not have been so effective had she suffered from tuberculosis or vitamin B12 deficiency.
What I end up with, after looking at the lives of healthy very old Christian Scientists, is a respect for their particular path. Much of what we, as physicians, hand out for diseases will someday be found to be at least as bad as blood letting, which does in fact work pretty well for both acute congestive heart failure and hemochromatosis. In a couple of decades we will cringe as we think of the patients who we treated with chemotherapy drugs for cancer who died of side effects with no significant beneficial effects on their tumors. I have seen a few tragic results of using faith healing to treat cancers, but I have also seen people who were diagnosed with relatively small tumors, treated with chemotherapy agents that made them feel terrible and died anyway. It seems clear that there are some people and some diseases that probably respond dramatically to faith healing and some that respond dramatically to the right chemotherapy drug.
My best friend in college, Elisabeth Targ, graduated from Stanford and became a psychiatrist who had a special interest in remote healing by non-denominational prayer. She attempted to rigorously test the effect of distant prayer on patients with AIDS and saw a significant improvement in their outcomes. The study was later questioned, but she was pretty impressed with the results when I talked to her before her death. She died of a very nasty brain tumor in 2002 despite prayer and psychic healing attempts from her very wide range of friends. The problem was, I think, that she just had a really bad disease that neither surgery, radiation, chemotherapy nor as yet undescribed psychic processes could cure. Watching her struggle with the side effects of her expensive chemotherapy drugs I would say that the psychic part of the healing was not nearly so nasty. Kind of nice, actually.
I think psychic healing and faith healing probably have an effect that is mediated by some of the same processes that are involved in the less far-out practices that are part of mind-body medicine. Meditation and guided imagery will be more easily accepted by the medical field because we come closer to understanding them and can more easily test them. The science involved in this will continue to be really difficult to do well, because you can't have a control group "pretend" to meditate, since even pretend meditation is meditation. Practices that can be taught and learned and repeated without medical supervision will be attractive for payers and this will partially counter the medical profession's reticence to use techniques that they feel are unscientific. Already the teachings of John Kabat-Zinn have been codified into a curriculum called "Mindfulness Based Stress Reduction" which has been spectacularly effective in treating conditions such as anxiety, chronic pain and insomnia. We will continue to learn what these sorts of things are good for, and perhaps we will move ever so slightly away from the modern approach of a pill for every problem.
Thursday, December 29, 2011
How does Canada do it?
Canada has a publicly funded insurance program that pays for basic health services and covers about 99% of outpatient visits. Doctors, though, are not all on a salary through the government, which I thought they were. Most physicians receive fee for service, just like they do in the US.
What happens is that their "medicare" is much like ours, and pays doctors for seeing patients. I am not at all clear as to what a doctor can bill medicare for, whether Canada pays for things like management services not involving face to face contacts or that sort of thing, which would be really interesting to know. Some doctors are on salary through community health clinics like they are here, but my Tanzanian friend said that those who work fee for service are paid more generously and have more control over their schedules, so that is what she has chosen to do.
I asked her how Canada deals with the shortage of primary care internists, since I figured this probably isn't a peculiarly US problem. She said that for as long as she has been aware, Canada uses its internists as consultants to the family doctors who are the real primary care physicians. The internist may see a patient several times in a year, but will give recommendations for management to the general practitioner who is primarily responsible for the patient's care. She feels that internists are paid well and have good lives. They do also take call at the hospital and usually provide inpatient care, but most are not "hospitalists" per se, but more what we would call traditional internal medicine physicians. Internal medicine consultants, in order to be paid at a higher rate than general practitioners, must complete a 4th post graduate year, a fellowship in internal medicine, which is one more year than US internists do.
This sounds to me like a truly great solution to the problem the US is having with too few internists. As a consultant I could take care of many more patients, but be less likely to be burned out since those patients would have another physician to help care for them, and as a consultant I would not have to be available to every patient all the time.
Once again, it looks like another country has figured out a solution to one of our problems and if we were flexible we could just adopt it.
Being a hospitalist and watching our hospital get digital
Since quitting my primary care job 2 months ago I have been working at our local hospital as a "hospitalist". I take 24 hour shifts, several in a row, and during those shifts I am responsible for taking care of all of the patients admitted to the hospital whose doctors can't care for them in that setting. This ends up with me being a consultant for some patients who are particularly complex and time consuming and being the primary doctor for patients whose doctors don't have hospital privileges or are out of town or who don't have a doctor at all. I meet lots of interesting people and get to know them and do the diagnosing, communicating and treating that they need until I go off duty. For many of these people I miss being able to see the whole illness through, like I used to do. It is freeing, though, to know that my responsibility ends at a certain time.
My days vary from extremely busy, where I can't even answer a phone call from my family and have to keep multiple juggling balls in the air all the time, to relaxing, where I can talk to nurses about their vacations and pester the ultrasound technicians to show me how to do imaging. I can sometimes leave the hospital during the day if I need to do something, and sometimes I can barely find a moment to jam some food in my mouth, and don't get to sleep much at night. Our hospitalist program is just getting going and we are working on making processes in the hospital fit us. We are trying to standardize our documentation (admission and progress notes) and still are pretty haphazard with regard to knowing exactly what and how to bill. We are a small hospital so we have only one hospitalist working at any given time, and we rotate shifts according to the demands of our lives and the availability of other doctors to fill in. We fill extra spots with doctors in the area who do this sort of thing and doctors from further away who we get through a physician recruiter.
Many small hospitals just hire a group that provides hospital services to do the whole program, hiring physicians, standardizing signouts, billing and that sort of thing. This is expensive, since the hospital pays heavily for the administrative services as well as the doctors. If a doctor doesn't work out (and in our experience, that does happen) there may be some conflict between the hospital and the hospitalist company. It's very much like the difference between hiring a babysitter oneself vs using an agency. I am glad our hospital is doing it our own way since it allows us to figure out what works best for us and keeps the lines of communication simpler. If we can't fill our spots, though, I bet the hospital administration will get desperate and hire a company.
Next month I will be working at a hospital a few hundred miles away which is larger than ours and which gets its hospitalists from a large hospitalist company. I will get a chance to see how a big operation does this stuff, which may help our organization stay independent. I will plan to continue to work at least some shifts at our hospital which will help me share what I learn. I will be working 12 hours a day for 7 days and then will have a week at home to recover. I'll be doing lots of driving.
Tomorrow is the last day of a block of 4 shifts that I have worked. It has been really busy. I think that everyone waited until Christmas was over to get sick and come in to the hospital because I've hardly had time to breathe. I have met lots of great people though. What has made work in December particularly challenging has been the fact that our hospital just adopted a computer system to handle nursing, ordering, lab and x-ray data. We had been inching along in that direction, but finally jumped into the deep end and now we have no lack of annoying hassles to commiserate about. The system comes from the McKesson company and is called Paragon. Superusers have been working on this for much of a year trying to write the program so it will fit us, but like all electronic medical records, it is full of weird little bugs, crashes, lags and unexplained inability to access what we need at inopportune moments. Some people are slower than others and we have had support staff resign over frustrations with it already. But having watched what happened when my outpatient office went digital, this is not as ugly.
I look forward to 2012, especially sleeping late on Monday and turning off my cell phone, however briefly.
My days vary from extremely busy, where I can't even answer a phone call from my family and have to keep multiple juggling balls in the air all the time, to relaxing, where I can talk to nurses about their vacations and pester the ultrasound technicians to show me how to do imaging. I can sometimes leave the hospital during the day if I need to do something, and sometimes I can barely find a moment to jam some food in my mouth, and don't get to sleep much at night. Our hospitalist program is just getting going and we are working on making processes in the hospital fit us. We are trying to standardize our documentation (admission and progress notes) and still are pretty haphazard with regard to knowing exactly what and how to bill. We are a small hospital so we have only one hospitalist working at any given time, and we rotate shifts according to the demands of our lives and the availability of other doctors to fill in. We fill extra spots with doctors in the area who do this sort of thing and doctors from further away who we get through a physician recruiter.
Many small hospitals just hire a group that provides hospital services to do the whole program, hiring physicians, standardizing signouts, billing and that sort of thing. This is expensive, since the hospital pays heavily for the administrative services as well as the doctors. If a doctor doesn't work out (and in our experience, that does happen) there may be some conflict between the hospital and the hospitalist company. It's very much like the difference between hiring a babysitter oneself vs using an agency. I am glad our hospital is doing it our own way since it allows us to figure out what works best for us and keeps the lines of communication simpler. If we can't fill our spots, though, I bet the hospital administration will get desperate and hire a company.
Next month I will be working at a hospital a few hundred miles away which is larger than ours and which gets its hospitalists from a large hospitalist company. I will get a chance to see how a big operation does this stuff, which may help our organization stay independent. I will plan to continue to work at least some shifts at our hospital which will help me share what I learn. I will be working 12 hours a day for 7 days and then will have a week at home to recover. I'll be doing lots of driving.
Tomorrow is the last day of a block of 4 shifts that I have worked. It has been really busy. I think that everyone waited until Christmas was over to get sick and come in to the hospital because I've hardly had time to breathe. I have met lots of great people though. What has made work in December particularly challenging has been the fact that our hospital just adopted a computer system to handle nursing, ordering, lab and x-ray data. We had been inching along in that direction, but finally jumped into the deep end and now we have no lack of annoying hassles to commiserate about. The system comes from the McKesson company and is called Paragon. Superusers have been working on this for much of a year trying to write the program so it will fit us, but like all electronic medical records, it is full of weird little bugs, crashes, lags and unexplained inability to access what we need at inopportune moments. Some people are slower than others and we have had support staff resign over frustrations with it already. But having watched what happened when my outpatient office went digital, this is not as ugly.
I look forward to 2012, especially sleeping late on Monday and turning off my cell phone, however briefly.
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