Why your doctor hates the EMR. The 500lb gorilla in the room that nobody is talking about.

Posted on May 14, 2013 | Leave a comment

So youve heard of the Electronic Medical Record, or EMR by now. Starting in early January 2015, the HITECH (Health Information Technology for Economic and Clinical Health).But its already been in use and incentivized since 2012.  And you may  even have an inkling of how it is supposed to help health care. Maybe you’re all for it. Maybe you’re not. Maybe you dont understand how it affects your health. Maybe you dont understand why your doctor doesnt look at you anymore, and stares at the keyboard when he’s talking to you. I’ve been compelled to blog about this, because I feel its damaging patient care. That may come as a surprise to you, I understand, but its the truth. And I have hundreds of doctors who can back me up on this. I know its mandatory, so dont freak out, I use mine to the letter of the law. But the EMR has some serious problems. Let me fill you in.

EMR

EMR

The biggest issue. Time. It takes alot of time to document in progress note. I spend about 25% of the day seeing patients, which is sad, because its actually my favorite thing to do. I sometimes think how blissful it would be to spend 80% of the day seeing patients like back in the 70s. Unfortunately most of it is spent filling out forms, prior auths, calling labs, medical equipment companies and going to sleep, group, and hospital meetings. And and dont forget the 2-3 emails per day regarding EMR, meaningful use and data. The EMR takes a considerable time of the 75% remainder of the day. And even more if you dont know how to type. (I do :) )

Face to face communication. Do you wonder why your doctor documents on a keyboard in front of you? Because this time isnt built into the day. We try to schedule the way things were before the EMR, and it doesnt always work. Which is why you wait in the lobby longer. Also doctors dont get paid for the time it takes to do the EMR notes, unless it is in front of the patient. They dont get paid if they document after the visit. Thus, you should go ahead an expect minimal eye contact. Its our govt regs at work, and it is the new norm. I have had many a patient leave their primary care docs for this reason alone. It is destroying the patient physician relationship. Paying attention, and catching nuances is important. And if youre typing on a keyboard during the visit, it doesnt appear that you care. Unfortunately, it cannot be escaped.

Downtime. Our EMR or fax servers generally go down twice a week. Typically for an hour, sometimes two. It may not sound like a problem, but when it happens, it cripples us. No paper charts. No backup. When it happens, we dont know who is on the schedule or even who is in our lobby. Sure we can fall back on paper during these times, but there is no access to names, records, or schedule. When the fax server goes down, our hundreds or inbound and outbound faxes get backlogged. Then the phone starts ringing. Where are the orders? Where is your referral?  The pharmacy says you didnt fax the script. A patient didnt get their work letter. And what can we do? Nothing. Unless you want us to snail mail it.

Improved care? It may or may not be helping patient care. With limited access to doctors, and time being filled with EMR use, we may be cutting patient access. Those that are here get less attention, as the focus is on EMR. We have dozens of EMR “rules.” Notes locked in 24 hours. Template requirements. Documentation requirements. Benchmarks. Meaningful use. Stuff that wasnt taught in med school. If you only had any idea. Not to mention, all that legacy data. What happens to the old paper charts- they get scanned in. So instead of flipping through pages, you have hundreds of PDF pages to resize and scroll through. Ever try to read a 100 page PDF?  Ever find it tough to find what youre looking for?  Ever give up?

What about when you have too many cooks in the kitchen?  You may have 10 doctors, and one med list. By right when a med has changed, it should be reflected in the list, and it often is. But we have learned that if you did not make the change, and another doctor did, its best to let them make the change. Otherwise it looks like the sleep doctor is making BP pill changes. “aka BP med list updated 5.14.13″, then you get a nasty call from a PCP office. So patients often say, I m not on these 3 meds anymore. We have to say, your pcp has to make that change. Its their responsibility and their liability. We dont manage them so we dont change them. Otherwise fur flies.

Paper charts

Our unused stash of paper charts – I miss ‘em

Oh and dont assume all docs are on the same EMR. Dont even assume all docs in the same practice or group are on the same EMR. Why does that matter? Because your progress notes are not able to be viewed by other docs taking care of you. Sure your tired of filling out forms and history and listing out meds 20x, but the fact is, only  a small proportion of use can see everyones notes. Dont assume we can. Thats why youre repeating it. EMR was support to improve patient care, but instead it blocks it. Its like having Windows OS, Mac OS, and Blackberry OS, trying to communicate with each other. They cant. Then you have to request notes from the other doctors (after an agreement form of course), have them print from the EMR, then fax 100 pages of documents…and a cover sheet. Thus creating more 100 page PDFs. Circular isnt it?

Jeter file cabinet

Jeter file cabinet- big time in the hey day of paper charts.

The software is beta. If you are a developer, you know what this means. Its crappy. Ours freezes, shuts down, logs us out, and fails to load templates…at least 3-4 times per day. Then we have to log out or reboot…while patients wait. It reminds me of Windows 3.1, and maybe you are too young to appreciate it. But it was terrible. Slow, buggy, and in the way if what you truly wanted to do. You see, with the mandate, physicians were forced to buy EMRs asap. And what a great advantage to EMR companies! You are forced to buy them, so just get a product out there, bad or not, they will have to buy it. Its like if you had to buy a Windows phone. Now. What if you didnt want one, or it was inferior to other products. Thats too bad. Its mandatory. Mandatory doesnt drive innovation.

I might add that, without a doubt, EMRs are designed by tech nerds who have never seen a patient in their lives. They blow smoke acting like they know but they dont. What you get is an EMR designed to be data mined by companies for profit (another very long and true story) and not something actually usable for a clinician. If you are reading this, and you are in the industry, take note. You are doing it wrong. If you want to consult a real physician who is a programmer, coder, and web designer, you know where to find me. Yes, I am willing to help. You need it. Badly.

So there you have it. Its all out there. This should give you a better perspective of where health care is and where it is going. Again, I’m not saying Im not using it. I cant, I’m mandated to use it. But it is killing out health care system. At the very least, the EMRs need to be one hell of alot better. At the best, there should be more flexibility with billing and time, so we can document after the patient visit and actually make eye contact. Isnt that what patient care is all about?

-Merican Dreamer

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Pack up the van, its time to leave Facebook. 10 reasons you need to hit the door.

Posted on May 2, 2013 | Leave a comment

For those of you who know me, you already know. I left Facebook about 3 months ago. And havent looked back. I’m about to tell you why. Some of the reasons are quite concerning. And I’m not alone. A whole segment of the US population has left Facebook. And if you are reading this link because a friend shared it on Facebook, I’m talking to you. Pay attention. Let me tell you what time it is.

delete facebook

Delete Facebook Credit:mailnoobsatwork.blogspot.com

1. Facebook is nothing more than a gigantic advertising machine. You are part of it. Instead of selling your data, you freely give it to Facebook, Inc. It can be used to sell to you, or allow others to market to you. Your posts are property of Facebook, as are your pictures. Mark Zuckerberg has been relentlessly pushing for non-private, public posts and data. He has stated “privacy is no longer a social norm.” Is this what you want for your life?

2. Employers are demanding to see, comment on and delete posts, despite them being part of your “private” life. What if you had a beer over the weekend and posted a pic. Suddenly a fun pic becomes an overblown nightmare. I’ve talked to 10 people with new jobs in the past 6 months. And I’m not just talking Walmart employees. Doctors. Lawyers. IT engineers. Its becoming the new norm.   All had their Facebook accounts requested to be viewed. Oh, you can say no, but of course, that might mean you dont get hired. Kinda funny, huh? Its alot nicer if you dont have one. Nothing to hide.

3. Your data is being indexed. Its called Facebook Graph search. This will be used so friends, and advertisers. Can find which of their friends have any specific interest, like, comment, or searchable item. Say you want to search your friends for males, under 40 who like Radiohead and are single. You will be able to do that. Soon. Supposedly by the end of 2013. Is that a little scary? It should be. Your privacy will be gone.

4. I’ve been on both sides of Facebook. Including the deep, dark, underbelly of Facebook. You see, nearly all of your data is searchable. I used to run ads for patients that mentioned the word cpap. Or had OSA as a like or favorite. Or that had commented about difficulty sleeping. Who lived in a 35 mile radius. Did that just make your heart stop?  It should have. Let me repeat it for you. YOU HAVE NO PRIVACY ON FACEBOOK.  And I’m not the only advertiser. There are millions.  Here are the 30 biggest. People always ask, how does Facebook make its money? Think about it. It sure as hell isnt completely free. Someones paying. For access to your data.

So while companies say their cutesy little lines such as “like us on Facebook.” Or follow us on Facebook, its just an advertising ploy, and you are sheepishly following it. Would you allow a door to door salesman in your house?  Then why would you let random advertisers into your life. Or your kids?  Or your parents?

Français : Bouton « J'aime pas Facebook » trad...

Français : Bouton « J’aime pas Facebook » traduit par le framablog. (Photo credit: Wikipedia)

5. Privacy is grossly underrated. I remember seeing the barrage of useless bilge on Facebook. Something someone purchased, or ate, or a pic they took on the beach that made everyone jealous. It became a showoff medium, a chance to flaunt what you can purchase. Heres a clue. If you ever find yourself taking a picture because “I should upload this to Facebook,” you have a problem. Pictures should be taken because you enjoy them.  Now that I’m off of Facebook, I have genuine interactions with people. When you put all of your events on Facebook, theres nothing to talk about, its already out there. And thats if you can even maintain eye contact for 30 seconds without looking at your incoming text messages and Facebook updates.

6. Word on the street is that this data is being used for profiling. Sure, you’re a good kid, and its only being used on bad people. Ever wonder how the news stations get access to all the pics from suspects Facebook pages? But what if it became more…oppressive. Data images that match you when you run a “pink” stop light. Or walk into work 60 seconds late. Or cross a crosswalk when its says don’t cross. All those camera images that run all around us can be used to match and ID, with your so generously provided pictures.  Just saying…

7. The tech guys are leaving. We are the early adopters. We were first to the party and first to leave. That should concern you. We see something you dont yet. You probably dont want to hang around to find out.

8. The numbers are falling. Facebook just took its biggest hit to date. 10 million people in the US left Facebook in recent months. Privacy. Security. Family. These are the drivers for leaving.

9. Teens dont think its cool anymore. I asked 4 classes of high school seniors if they used Facebook. Out of 160 students, I got 10 hands. Seriously. When asked why, they said “its for old people.” How about some cold water on your Face. Just to make you realize I didnt skew this, I asked how many were using Twitter and Snapchat. Nearly all hands went up. You dont think this is why Facebook bought Snapchat do you? (inset eerie ghost sound).

10. It is becoming increasingly the cause of social distress, lawsuits, and marital issues. I have a few psychiatrist friends, who tell me that half of the problems she sees involves Facebook. Who friended who, who friended an ex, who poked who, who saw which picture, and who posted a party pic and was fired. It can get you into serious trouble. Trouble that can easily be avoided.

I might add they also have been seeing people for Facebook addiction. If the thought of leaving Facebook or not checking in for a few days gives you cold sweats and/or anxiety, you may be among them.

So do yourself a favor. Leave Facebook. (Click link and sign in to actually do it.) Dont be afraid. Go back to your private life. Seek enjoyment over the things you do, and the time you spend with company. Dont fall prey to advertisers. Get your life back. You were fine before Facebook, and you’ll be fine after.

-Merican Dreamer

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On running, watching, and working as a doctor in Marathon races. Boston changes everything.

Posted on April 16, 2013 | Leave a comment

When I heard of the explosions and saw the bombs at the finish line, my heart stopped. This was an atrocity. This was God-awful. It hit home for me in several ways, I am about to detail. How could something so horrific happen to the worlds best athletes, at a time of celebration. Who would do such a thing?

If you dont know, you cant just decide you want to run the Boston Marathon. You have to qualify. Generally that means you have to run a marathon in less than 3 hours 15 minutes. Most people cant run a marathon, and most who can average a mean of about 4:32.  Many people train for years, decades even to be able to make it to the Boston marathon. And the qualifying times get harder every year. My neighbor has been running 60-80 miles per week for the past 3 years, and hoped to get to Boston next year. He is 15 minutes away from qualifying. So those injured in the blast where likely in a moment of revery, finally seeing the finish line, only to have their dreams destroyed.

Its surreal to me. I was just in Boston. I was there for a sleep conference at the Boston Convention center last June. I recognize the subway stops. The restaurants. The shops and stores. We ate at Atlantic Fish in a torrential downpour. And now we see the images of the destruction from the bombs right in from the restaurant, on Boylston. We hear the familiar Boston accent we had heard all week, now making 911 and dispatch calls. What a tragedy to such a great area.

Boston Marathon

Runner injured in bomb blast, Boston, MA
Image :Boston Globe  www.BostonGlobe.com

 

I also think of the families, waiting for 3-4 hours for their loved ones to cross the finish line, so excited to see them achieve their dreams. Waiting and waiting and waiting, only to have a horrific ending to what was to be a pinnacle event in their lives together.

Ive ran a marathon before, and someday I will again. I can tell you when you are about 1 mile from the finish, you are literally on cloud 9. You start your kick. You begin to lose some of your senses. Your legs ache in pain. Your stomach in knots. All you want to do it hit the finish line and lie down. That never happened for dozens of runners. Their senses mangled, Im sure many of them wondered what the hell was happening. How can this be?  Am I dreaming this? I’m so close. Should I cross the line? Was that a bomb?

And as a volunteer in the medical tent. Working a marathon is always a volunteer event. All those medical personel. Yeah, they donated their time.  I’ve worked the medical tent half a dozen times at the Akron Marathon. Its generally a “fun” day. You deal with athletes. You get people back on the road. You fix burns, cuts, scrapes, dehydration, bee stings. At worst you see extreme dehydration and hypotension. Those runners get revived and sent stat to the ER. You dont see death. You dont see missing limbs.  You dont see blood. A generally fun day became a horrific nightmare for dozens of doctors, nurses, and hospital personnel. To think that at least 3 people woke up to enjoy the race, living life just fine, and are now dead, numbs me. My heart goes out to the doctors who did the best they could with the types of grim situations they faced.

And what does this mean for the future of racing?  For outdoor athletic events. I predict several things. Of course security will increase. No doubt about it. But how do you secure 26.2 miles?  How do you secure it a week in advance. What about the start line?  What about the finish line?  What about the stadiums that make it into many races. Every manhole, garbage can, mailbox, parked car, building…its endless. It will be nearly impossible to make races completely “safe.”  And you can expect those entry fees to go up. More police and more security cost more, simple as that. I also suspect many smaller races will simply end, not having the finances or staffing to keep up with the changing face of our society. Lots of questions to answer. What about high school sports? College sports?  Community events. The Cleveland marathon is about a month away, and WKYC and WEWS are already reporting that security will be ramped up. And last year the biggest concern was the heat.

The Boston bombing has changed things considerably. We are entering a new era of racing and security. Medical personnel will have to be on guard for weapons and bombs, not just cuts and bruises. Runners will have to be on the lookout for any anomalies, not just their pace and water stations. I ran a race on Sunday, sick as hell, but did finish. But one thing I will be able to say; I remember when the only thing I had to worry about during a marathon was finishing. Thats all over now.

-Merican Dreamer

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Oh the joys of summer! Running and relaxing in northern latitudes.

Posted on April 10, 2013 | Leave a comment

Well its finally here. Warm weather has made it to northeast Ohio. We thought it would never come. It has been cold, rainy, and generally depressing for the past 6 months. Yeah, I know thats OH. (yawn). But it seemed to never end this year. Just 2 days ago it was 26 degrees. And now its 81.  It seems the the winter demons have finally moved on.

English: Sunrise at North Point Park, Milwauke...

English: Sunrise at North Point Park, Milwaukee, Wisconsin Français : Lever de soleil à North Point Park, Milwaukee. (Photo credit: Wikipedia)

And now the the joys of summer. Sure its spring, but whatever. Ohio only has 2 seasons, apparently, given the temp extremes of late. How about ice cream on a hot day. The sunrise in the morning when the humidity is so thick it makes you cough. Buying tons of plants and fertilizer at Lowes and Home Depot. Hanging out on the patio with friends and neighbors. Running the roads and trails of Northeast Ohio. Outdoor concerts at Blossom Music. Watching the Tribe on the homerun porch. Watching your hometown fireworks, and the smell of combusted gunpowder. The smell of fresh cut grass. Jimmy Buffett on the radio. Tiki torches. Telling lies and watching the sunset. Sleeping with the windows open. This is summer. It is finally here. Enjoy it now, for it gives way to winter in less than 6 months.

English: Summer Solstice 2005. Sunrise at Arbo...

English: Summer Solstice 2005. Sunrise at Arbor Low on the morning of the longest day. View over earth bank surrounding the circle. (Photo credit: Wikipedia)

My personal favorite?  June 21 or 22, depending on the year. Summer solstice. The longest day of the year, by sunlight hours. Its simply magical. If only it could be that way forever. Then June 23, the days start getting shorter, and dawn moves closer to dusk.

So get out there and do something. And for the love of God, dont complain that its too hot. “Nothing gold can stay.”

-Merican Dreamer

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The Coming End of the Smartphone Era

Posted on March 27, 2013 | 1 Comment

Thats right kids. All good things must come to an end. Just like college, twinkies, and single life.  The smartphone has certainly lived its life and been woefully popular. But now we are beginning to see the limitations of a smartphone, and some of the social problems.

Cracked phone display

Cracked phone display (Photo credit: hugovk)

Socially, you notice how people and families are making less eye contact, and talking less. How about texting and driving. It wasn’t an issue about a decade ago.  And now it is.  Texting will become obsolete as voice dictation takes its place.  Why use a keyboard when you can just talk, and leave your hands free? Or just make a phone call.

Samsung just released their next phone, the Galaxy S4. But only a few wow features. Weve now hit Max resolution at 1080p. Over 440 PPI. Quad core processor. Ability to track your eyes for video. Pretty impressive, right? Well, theres not much left in the tank to top that. So what are the companies to do?

From a device standpoint, we are reaching a maximum of what devices can do. Honestly is there really anything you wish your device could do that it cant?  Other than driving your car and going to work for you? (Note:one day cars will drive themselves, see driverless cars from Google, and the fact the California is the first state to allow driverless cars.) Smartphone manufacturers are running out of ideas and planning their next platform.

Sony SmartWatch Review

Sony SmartWatch Review (Photo credit: clintonjeff)

Introducing…The smartwatch. Have you been following the news lately?  Google, Apple, and Samsung have been clamoring for smartwatch patents. There are also some low end devices out there now that can be synced to your phone.  This allows us to move away from visual devices for communications and perhaps, use a tablet only for video and image viewing.

And then theres Google Glass. These are smart glasses. Able to do most of what your smartphone can do by voice command alone. The images and notifications appear in front of your lens. Google recently made big news for having the first beta sales at $1500/pop. But I’m sure by 2016, they will cost under $500. Glasses allow us to focus more on the world around us, like an augmented reality, instead of looking down at our hands. They also allow us to use our voice to take pictures, video, get directions, and make phone calls. If this video doesnt make you want one now, you have no pulse.

Google Co-Founder Sergey Brin Sports the New G...

Google Co-Founder Sergey Brin Sports the New Google Glasses at Dinner in the Dark, a Benefit for the Foundation Fighting Blindness — San Francisco, CA (Photo credit: Thomas Hawk)

So not only are we hitting  an inflection point in smartphones; the companies are sending their best and brightest developers into new projects, and spending time away from smartphones. Both of these will cause smartphones to stagnate over the next few years. And before long you too will have a smartwatch or Google glass. You may even reflect back on these days and read this post.  Or have Google read it for you.

-Merican Dreamer

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Wait a second…my medical office needs a website? Why doctors need to hang their 21st century shingle. Or get left behind.

Posted on March 6, 2013 | Leave a comment

I just spoke at a regional conference and had the opportunity to talk to over 100 physicians. I, you may already know, own a web design firm, which caters predominantly to physicians and medical personnel. I was surprised to find out many thing these docs, old and young did not know about the web…

In case you didnt already know, the Yellowpages and AT&T listings are dead. Theyre as dead as the residential home line. If you’re paying alot for them, often $3000 or more, its time to stop. Put your money somewhere else. Somewhere more visible, more interactive, and where you can control the content.

When patients and customers are trying to find you, they dont reach for a book, thats so 90s.Google

They grab a smartphone and start a Google or Yahoo search. Sometimes its on a map. Sometimes its in a browser, or Yelp.  What if you’re not there? What if your competition is? Well, I’ve got news for you. You’re late to the party. Its time to get a website.

Oh I’ve heard all the excuses. Now is not the right time. I’m too busy, I dont need more referrals. I work for a massive conglomerate system, I have “my own” page. All of the excuses listed above are short sighted. You want something you can call your own. Not a subpage, not a tiny address listing. And if you think you’re busy enough, just wait. When your competition puts out a site of their own, you will lose volume. I know. I started one to compete with the other 15 sleep docs in the area. Plan for the future, not the afternoon, muchacho.

With you own site, you can control all the content, and often it will rank high in the search results. (BTW I know many tricks to this, which is why I am a consultant).  :) Patients will find you. You can add office hours, office forms, and even take a nice picture of yourself (one where you’re smiling, and not scaring off customers) and staff to put on the front page.  People want and demand this type of info. Otherwise, they will view you as being old school, and even worse, obsolete. They will find another doc, who may or may not have as much training or knowledge as you, and go to their site.

stats

How do I know this?  Because I have been heavily analyzing data from the past 6 years of my sites. Did you know you can see where traffic comes from?  How long people are on your site?  Which OS they are on?  Which browser they are using?  Even age and demographics?  Thats right kids, the web is not private. This information can be used to your advantage. As a sleep specialist, I get many, many referrals right from the web. They dont see their pcp, they dont call Summa operator. They come directly to me, and do not pass go. 1/4 of our referrals come this way. Those are big numbers, on order of 1000s per year. Make no mistake, youre website pays for itself.

If you’re thinking about it, or just want to talk about it, or just want to learn more – contact me. After all, I’m a physician too. I know what you want, and I know how to talk tech geek and physician, and am fluent in both – a skill which nearly nobody has. In fact, I am the first physician owned, physician web design LLC in the US.

CWD

www.consultwebdesign.com Web Design for physicians, by physicians.

-’Merican Dreamer

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Why it is futile to lie to your sleep doctor, aka big brother is watching your cpap.

Posted on February 27, 2013 | Leave a comment

Do you have sleep apnea?  Do you wear cpap or bipap? Or maybe you dont wear it as much as you should….ahem.. Well, its time for me to tell you a secret. I already know.IMG_3700

Whats that?  Yes, your machine logs hours for over 5 years. It can easily tell me how many hours youve used it in the past 5 years. How many hours on average, whether you wore it last night, and whether you started using it, just in time to see the ‘ol sleep doc.

In fact, if you run a diagnostic report on compliance, which your medical equipment company can do. I can actually tell you the exact  time and dates you wore it, ie 9:56PM-5:31AM Friday Feb 22, 2013. Amazing technology, huh?

CPAP

CPAP (Photo credit: Pete Prodoehl)

You see if your insurance is paying for the equipment, or Uncle Sam, they want to be sure that you are using it. So they required compliance monitoring on all devices made since about 2000.

Oh you have a trick…you just turn it on at night, and put it in another room. Yeah, I know that one too. You see, the machine registers blower hours and therapy hours. And when one is 1000, and one is zero, I caught ya. You’re not wearing it. You’re just turning it on. The machine knows the difference.So once and for all, if you found this post, consider yourself educated.  You can run, but you cant hide your non-compliance…unless (gasp), your doctor doesnt look at your machine.  (Insert lonely howling sound where tumbleweed rolls across the street.)

IMG_3698

And if you arent wearing it, you are subjecting yourself to tons of heart disease, stroke, hypertension, diabetes, sleepiness and a multitude of other risks. Guys, you may want to read that last one on the link carefully…thats right ED!!

So take care of yourself, and hey, use that cpap, or find someone to help you.

-Merican Dreamer

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Why healthcare is so expensive, and what our leaders have failed to do to stop it.

Posted on February 15, 2013 | 1 Comment

So you see the news every day, healthcare is more expensive. More unnecessary tests are being ordered. More medications are more expensive. Seniors are getting less health benefits. Baby boomers are requiring more health care. The nation is more obese than last year. Less doctors are going into primary care. Insurance premiums are going up. Businesses cant afford to offer insurance.

English:

English: (Photo credit: Wikipedia)

Do you ever stop and wonder why?  Do you ever wonder what doctors are talking about en masse?

Well, sit back, and grab a cup of coffee. Let me tell you about the medical world.

There are 4 reasons for the rising cost of health care.

1. An aging population- older people need more health care, its that simple. If more baby boomers are getting older, they need more health care, and thus, costs will rise. Nothing can stop it. Otherwise, its like saying 100 people should cost the same to care for as 200. It doesnt make sense. More care costs more.

2. Medical litigation- Something the politicians try to hide or dismiss this. And something doctors cringe to talk about, and look the other way. But defensive medicine is real. It costs hundreds or thousands, even millions per year to insure a single doctor. And its imputed into aggregate medical cost. Where does this cost come from? What is malpractice so high? It is this cost for absolute certainty. We all learn volumes and volumes of medical knowledge. We know the rules and presentation of disease. But medicine is an art, not a science. 95% of medicine follows the rules, 5% of medicine, does not follow the rules. The population and lawyers are not happy with being 95% sure. They want 100%. This degree of certainty comes with a cost. Diagnostic testing and labs. Sure we could avoid it, but then what happens when a diagnosis is missed? You got it. Lawsuits and legal fees.

So yes, defensive medicine is real. Its a bad word, but it drives up medical costs in three ways, malpractice insurance cost, additional testing, and litigation costs. Often times bad outcomes are just as bad as bad care. For example, I know of several instances where smoking patients were told numerous times to stop smoking. Then they got lung cancer, then the families sued. And won. Does that make sense? Is that really a physicians fault? This cost is being passed back on to you, in the form of hospital costs and fees.

For the record, yes, I agree there are some bad doctors,  but an overwhelming majority (read as greater than 90%) of physicians got into this for the right reasons, always try to do the right thing, and care deeply for our patients.

Picture of an Obese Teenager (146kg/322lb) wit...

Picture of an Obese Teenager (146kg/322lb) with Central Obesity, side view.Self Made Picture of an Obese Teenager (Myself) (146kg/322lb) with Central Obesity, Front View. Feel Free to use. (Photo credit: Wikipedia)

3. Obesity and poor diet- If you dont already know this youre living under a rock. I could talk for days about this, but its this simple. We are unhealthy. We continue to grow larger, and get more unhealthy. Here is the key to solving this. Ready? Personal responsibility. Without it, nothing changes. We preach all day long about health, smoking, exercise, etc. But if that device is not heeded, as it often isnt, health gets worse.  Its not our fault, we do instruct. Its the recipients fault, for not caring about their health, and making real changes. We cant spend all day with you, choose your foods, prevent you from overeating, from taking your meds incorrectly, from not exercising. And we cant tuck you in at night either. At some point you must accept personal responsibility.

4. Cost of innovation- new tests, new procedures, better drugs with less side effects. Theyre great, and they are funded by NIH grants and private corporations, but they drive up cost. Older generic meds may be just as effective, but they arent advertised, and some are being manufactured less and less, to make room for more expensive drugs.

Congress has by and large failed to address these issues. They are often funded by big corporations that support drug makers and drug manufacturers. Isnt it ironic? Dont ya think? Meanwhile, they try to cut health care services to their populous each year. What has been done about malpractice at a national level? Nothing. What has been done to incentive patient health at the national level? I am not referring to “exercise campaigns” in January. I mean hitting people in the pocket book if they are unhealthy. Nothing.

The leaders talk all day about what doctors need to be doing. Ordering less tests. Educating patients on obesity and diet. I have news for you *and them*.

Exchange Money Conversion to Foreign Currency

Exchange Money Conversion to Foreign Currency (Photo credit: epSos.de)

We do. All day long. It isnt heeded. It isnt working. 

How do we solve this? Incentivize health.

How? I’m glad you asked.

1. Everyone pays something. Many people get totally free healthcare from uncle Sam. Approximately 20% of the population. Seriously. No copays, no medication costs, no cost for equipment, no cost for studies. Zero. And you know what? They are the unhealthiest among us. Paying something, anything, for healthcare puts you in the game. If you pay for your insurance, you tend to take better care of yourself, you use less services, and go to the ER less. If healthcare is free, you have no concern how much healthcare you consume. Life is a medical buffet. You can noshow your appointments (as they often do), miss taking your meds (even though you have them for free), and show up at the ER for toe pain (happens all day long).

2. The unhealthier you are, the higher your premiums should be. Aetna, Kaiser, and other insurances have started doing this. If you smoke, your cholesterol is high, you are obese, or have high blood pressure, you pay more. Its that simple.

We dont discount car insurance to bad drivers, so why do we do so for bad patients?  Let me put it in perspective for you. When a healthy, non smoking, marathon runner with a BMI of 24 pays the same as a morbidly obese diabetic who had a stroke last month, and was admitted for 4 days, it doesnt make sense. The second person is utilizing far more services. And they are likely to continue using more services. The marathon runner gets no discount. His insurance funds the obese persons medical utilization. Doesnt make sense does it? And guess what. If premiums went up for the obese, and down for the healthy, our nation would get alot healthier. Fast. And health care would be affordable. For the healthy.

Tasty Food Abundance in Healthy Europe

Tasty Food Abundance in Healthy Europe (Photo credit: epSos.de)

So there you have it. Perhaps Ill tell you more in the future. But chew on this for now. Let me know what you think in the comments.

-Merican dreamer

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Preparing for ABIM MOC board recertification. A painless process? Maybe…

Posted on February 1, 2013 | Leave a comment

Well, its that time. Just when you thought it was safe to go back in the water.  Its been 5 or more years since you took your ABIM, and guess what. Its time to recertify.  Well, now, its not actually due until 10 years after you take boards, but if youre a specialist that needs to recert in primary care medicine….lets just say the sooner the better.

Early Blake boys studying

Early Blake boys studying (Photo credit: Wikipedia)

I know, you just got that heart sinking feeling, like the one you get at the peak of the first hill of a roller coaster. “Damn, not boards.”  Well, I’m here to tell you. You can do it. Its gonna take lots of time, of course, but its straightforward….and it will cost you about $2500.

Step 1. Remember your ABIM number, and password. You probably forgot it, just look on your certificate, and have them email your password.

Step 2. Register for MOC, aka Maintenence of Certification. Wham! $1840, if you are a specialist planning on recerting 2 boards. There goes your free money this month.

Step 3. Buy MKSAP 16.  $519 (or less if you are an ACP member, or find an online coupon. :) Begin studying your ass off.  Spend 1-2 hours daily studying. I know what you’re thinking. What about Medstudy?  It was ingrained in us when we were residents. Certainly its a personal preference, and I have them both. I used to be a disciple of Medstudy, but no longer. MKSAP has come a long, long way from the terrible black and white boring read it used to be. It now has color photos, easy to read text, and summaries on nearly every page. And the questions are relevant. Taking MSKAP questions after reading Medstudy is like learning to drive in reverse. Its not worth effort. Strong recommend. MKSAP. You heard it here folks.

Step 4. Block off the dates for taking the recert, so you don’t have to move patients later.

Step 5. Register for boards when the date becomes available. This year its May 1, 2013.

Now pay attention. You will get your CME for the year AND 80% of your MOC points from MKSAP. When you read and take questions they will fulfill criteria for both. There are over 174 CME credits, and well over 100 MOC points. Just fill out the forms online at mksap.acponline.org after each test.

Outlier. You will need one practice improvement module to get the last 20 points for your MOC. I chose sleep, naturally, and cpap compliance. Think of a decent idea, plan it out, and do it. Its not that painful.

Painful

Painful (Photo credit: zubrow)

Before you know it, you will have your CME for the year, your MOC points, and you PIM done. Now all you have to is study more. (Insert sad trombone sound.) But at least its on your time. And the material is highly organized.

So there you have it. I just saved you 10 calls to MKSAP and ABIM. I’ll accept your thanks.

Questions/Comments, add below.

-’Merican Dreamer.

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Running without a wire. My review of the ipod nano 7th Generation: A runners perspective.

Posted on January 27, 2013 | Leave a comment

Well, between running and web design,  an annual rite of passage has occured. It happens every year about this time. My MP3 player, an iPod nano 6th generation started to fail. The headphone jack started to get crackly. Its not the first time. Some players crack, fall, get spring rain on them, fail from a software perspective, get destroyed during a race. Honestly, its my 15th 0r 16th MP3 player…remember the RCA lyra. Yeah, I had one, compactflash, 8MB of on board storage (the kids under 18 just lost their lunch) I know. That was top shelf back then…retailed for $224 back in 1999. But enough about me…

Apple Ipod nano 7th gen

Apple Ipod nano 7th gen

Sooo, naturally I upgraded to the Ipod nano 7th gen. It looks beautiful, it is a little bigger and weighs a little more. But more memory, I’ll take that. And a bigger screen. Sounds good. And I bought it for $115 used on Amazon (from a university track star, also another story)…seems like a deal.

Well this morning, I jogged with it. I read all the runners reviews, I know…no clip like the nano 6th gen. I was prepared to deal with it. Well, let me tell you. I hated it. They were right. The clip is a big fn deal. Why? Because, otherwise you have to hold the damn thing while you run. I had forgotten how much of a PITA (pain in the ass) that is. And oh, when you sweat, the thing gets so slippery, it falls out of your hand and swings in front of you, its miraculous save from death only a virtue of being connected by the umbilical cord that is your headphone set. And damn if I didnt accidentally skip tracks and pause at least 30 times on my 5 mile run. I had it. It was being sold again on amazon. I was going back to a 6th gen. They were cheaper now anyways. As the running reviewers stated, the clip was a deal breaker.

Then I had an awful idea…I thought of something I hadn’t before. What if…wires needn’t come from the store. What if wires werent needed at all. What if I didnt have to hold the damn thing because it could be controlled remotely. The saving grace of the 7th generation:Bluetooth.

ipod nano 7 bluetooth

ipod nano 7 bluetooth

And like that…I was off to Best Buy to find a bluetooth headset. Now I had tried this before with an Android phone. Too bulky to run with the phone, not to mention dangerous running with a $500 device. And the headset had alot to be desired, the motorola s7, s8, s9, s10…tried em all. Also tried Jaybird sportsband. They all failed. The motorola bounced up and down on my head like a child on a hotel mattress. Hard to run like that. The Jaybird squeezed my head the entire time, like a rusted vice on an old workbench (hi dad).

But nay, this time, I found something nice…an open box Motorola S305. ($40 Amazon, and though they are $50 at Best Buy, they priced matched, and saved my 4 days wait time :) )

20130126-221637.jpg

I paired them up with the nano in 30 seconds, and it was like magic.  The bluetooth worked up to 30 feet away, and one floor away from where I was. It was phenomenal. I could run 6:40 miles with nothing to hold. Nowhere to look but the road ahead. And I could control the tracks, volume and pause with the headset. The bass was rich and deep. The headset didnt bounce up and down, didnt fall off my ears, (like the new apple earpods- garbage) and yet it was light enough to feel comfortable for 10 miles.

Now sure you could be saying, you could just do that with you iphone. Why even buy the nano?  On the treadmill on a 10 degree day, yes, I could use my iphone from a floor away. But out there on the streets, on the perimeter… No.  I would much rather run with a $115 device than a $500-600 one.  And since you can control it remotely, and never have to look at the ipod while you’re running, you can get an aftermarket belt clip or armband that protects it, and doesnt need to allow access.  This is a major game changer. Instead of looking down at your side, advancing tracks and pausing, you can focus on your run.

Fellow runners and fitness gurus will also like the Nike plus feature, the stopwatch for running lap splits, and the 16gb base model storage, to fit your entire itunes library into. Even those Bell Biv Devoe tracks. (I know you have them, its ok).

So there you have it. Despite a very bad first impression, the ipod nano 7th gen holds weight and possibilities for us runners.  I’m told bluetooth headphones will progress and get even smaller in 2013, hence why bluetooth was included in this generation. But starting now, technology is on par with what is needed on the trail. Now get out there and PR. The future is clear. Running without wires.

Dont stop believin'!

Dont stop believin’!

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