HealthCamp Philadelphia–Less than a month to go

The BarCamp movement of self-produced intense conferences reminds me of the charrettes I'd hear about from my close friend and college roommate when he was in architecture school. HealthCamp has grown out of BarCamp and on Saturday, March 28, 2009 HealthCamp Philadelphia begins at 8:00 AM in the Hamilton Building on the Thomas Jefferson University at 11th and Locust Streets. The slide show summarizes the day and its goals.

Comparative Effectiveness Research–The View from Wachter’s World

Bob Wachter discusses the challenges of implementing the comparative effectiveness research results we have in hand. From the perspective of leading physicians and frequent contacts with a diverse range of specialists and sub-specialists in my tertiary care providing community, teaching hospital I find myself nodding in agreement with Wachter's observations.

Everyone but the citizen's ox gets gored by comparative effectiveness research implementations. I use the term citizen advisedly, taking my cue from Obama; for some number of patients may well feel that they lose out as individuals, even as the polity benefits.

Tough implementation ahead with lots of squabbling before we're done accomplishing a fraction of the result the policymakers are seeking.

Customer-Consumer Confusion and now Patients, too

EP Monthly's "WhiteCoat's Call Room" posts two links and discusses "Patients or Customers"?

Patient, customer and consumer have specific meanings, not accurately used in the posts from Aggravated DocSurg and Detroit Receiving's EM Blog.While I'm in general agreement with many (not all) of the sentiments expressed in the two posts, it's important to get the correct meaning of the terms.

Customer= he who pays
Consumer= he who uses

The definitions are from Princeton Wordnet, but they're the same as what I was taught at Wharton 20+ years ago.

Part of our challenge in forming relationships in the ostensible business (good or service exchanged for value) is that for many users of physician services (i.e., patients) both the patient and physician experience customer-consumer confusion with consequent misalignment of incentives.

Patients will be increasingly demanding of receiving value in their care for value given directly (fee-for-service) or through employer and tax-based services. They will find the employers holding them accountable for "smart shopping" or the government steering in other ways–or both.

My father was a proud physician, he cared only for patients. Were I to view the world as he did, I would be struggling to feed my family. In this year of the 200th anniversary of Charles Darwin's birth, let's remember that it is not only individuals, but also entire species and perhaps professions for whom survival is not guaranteed; one must adapt or die.

Emergency Physicians “When in doubt, they image.”

Or so says Internist Robert Centor at DB’s Medical Rants. He then goes on to offer the predictable rationale of malpractice risk as the driver for this behavior. KevinMD weighs in and cites GruntDoc who advances the economic calculation which suggests there’s little benefit to attention to this phenomenon. A lengthy and continuing exchange of comments can be found on DB’s and GruntDoc’s sites.

At least some emergency physicians order the imaging we do because other physicians want us to do so. The ED has become the defacto “unfocused factory” where the emergency physician is expected to work up the patient to the point that the patient can be admitted to or referred to the specific focused factory for definitive care.

Today our hospitals and physician practices manifest a myriad of focused factories, the chest pain-ACS focused factory, the joint-replacement focused factory, the respiratory distress-COPD-CAP focused factory and I could go on at length. This is exactly what the specalist medical environment wants–indeed insists that the hospital deliver and we emergency physicians respond.

Furthermore, hospitals have come to realize that with approximately half of revenue generated by patients admitted through the ED it makes sense to concentrate resources on the workup of these patients. Thus hospital diagnostic, treatment and support services focus on ED patients–not the least because those patients arrive to the hospital 168 hours every week. Hospitals, including my own, have installed the most sophisticated 64-detector, dual-source CT-scanner in the ED so that we will use them to better define which of our patients require which specialized services.

When physicians stop pointing fingers and start accepting the reality of industrialization of our once professional, cottage practice we may be able to generate intelligent patient-centered alternatives to the financial policy driven managerial practices we presently experience.

Engage with Grace


Engage with Grace is a project I learned about a month ago at the Health 2.0 Conference. Alexandra Drane presented the very personal story of her sister-in-law’s death, at home and in direct opposition to the recommendations of her physicians. About 1000 people in the room and you could hear a pin drop–except for occasional sobs–mine included.

Several dozen bloggers in the health care field and beyond are engaged in a blog rally* this weekend, simultaneously posting the one slide and Alexandra Drane’s post to
encourage conversation about a topic that’s often avoided but every family ought be discussing: How we want to die.
Please try it, using the slide above as a discussion guide. It’s not
that hard to have the conversation with your loved ones once you get

We make choices throughout our lives – where
we want to live, what types of activities will fill our days, with whom
we spend our time. These choices are often a balance between our
desires and our means, but at the end of the day, they are decisions
made with intent. But when it comes to how we want to be treated at the
end our lives, often we don’t express our intent or tell our loved ones
about it. This has real consequences. 73% of Americans would
prefer to die at home, but up to 50% die in hospital. More than 80% of
Californians say their loved ones “know exactly” or have a “good idea”
of what their wishes would be if they were in a persistent coma, but
only 50% say they’ve talked to them about their preferences.But
our end of life experiences are about a lot more than statistics.
They’re about all of us. So the first thing we need to do is start
talking. Engage With Grace: The One Slide Project
was designed with one simple goal: to help get the conversation about
end of life experience started. The idea is simple: Create a tool to
help get people talking. One Slide, with just five questions on it.
Five questions designed to help get us talking with each other, with
our loved ones, about our preferences. And we’re asking people to share
this One Slide – wherever and whenever they can…at a presentation, at
dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven’t had.Here is what we are asking you: Download The One Slide
(that’s it above) and share it at any opportunity – with colleagues,
family, friends. Think of the slide as currency and donate just two
minutes whenever you can. Commit to being able to answer these five
questions about end of life experience for yourself, and for your loved
ones. Then commit to helping others do the same. Get this conversation
started. Let’s start a viral movement driven by the change we
as individuals can effect…and the incredibly positive impact we could
have collectively. Help ensure that all of us – and the people we care
for – can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.
(To learn more please go to This post was written by Alexandra Drane and the Engage With Grace team.)

* In case you are wondering, "blog rally" is a term invented this past weekend
A blog rally is the simultaneous presentation of identical or similar
material on numerous blogs, for the purpose of engaging large numbers
of readers and/or persuading them to adopt a certain position or take a
certain action. The simultaneous natu re of a blog rally creates the
ironic result of joining the efforts of otherwise independent bloggers
for an agreed-upon purpose. As far as we can tell, this is the first
recorded use of a blog rally — occurring from November 26 through
November 30, 2008, in support of a viral movement called ‘Engage with
Grace: The One Slide Project’ — organized to encourage families to
discuss end-of-life care issues while gathered together for the
Thanksgiving holiday weekend. This particular blog rally also has a
parallel component on Facebook, where many people are donating their
status to bring attention to Engage with Grace.

I must credit Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston whose blog, Running a Hospital is where I learned of the weekend "blog rally". Levy is also on Twitter as PaulFLevy.

Employment Arrangements for Emergency Physicians

I meet once a month for breakfast with our EM residents. I learned this from my mentor, David Wagner, who started it well after I was no longer his resident and was serving on his faculty. I know the residents loved having his ear for an hour and there was a lot of give and take. I’ve been doing this now for five years and our sessions have never had much give and take. The ground rules for the hour are that I have to be able to act on information that I hear, but that nothing I hear will be attributed to the individual. Sometimes more is said than other times, but last year it finally occurred to me that some structure might be useful, particularly if focused around content not usually part of the core residency educational program. While all residents get some exposure to administrative topics, it seemed logical to focus more on these areas.

So as with many things, "Breakfast with the Chair" at my shop in 2008 has become more structured than what I fantasize Dave’s were, back in the day. I’m using these sessions to talk to the residents about "life, the Universe and everything." Or at least to discuss some of the basics of selecting life, disability, travel and other sorts of insurance and what’s on every senior resident’s mind at this time of year: getting a job.

Tomorrow morning I’ll discuss the various models of employment offering complete descriptions and trying to avoid judgments, though commenting on the strengths and pitfalls of each as I understand these. On the list will be the following:

  • Hospital Employed
  • Corporation Employed including single owners, small and large ownership groups, publicly traded corporations
  • Independent Contractor models with and without your own Professional Corporation
  • Locum Tenens
  • Democratic Group grant/earn-in/buy-in models

I’m going to point them to this page with the suggestion that they pose their comments and questions here, too.

Certified Physician Executive Tutorial

So I’m sitting at my sister’s in Palmetto after four days at the American College of Physician ExecutivesCertified Physician Executive Tutorial. I have to admit I was reticent to even tell colleagues what I was off for this week. It seemed like a silly waste of time. Friends and colleagues had queried me, “What are you, a ‘Wharton MBA’ doing taking this ridiculous course. When held to account I spoke about “getting my ticket punched” but this week turned out to be a wonderful experience. I should have known it would.

The key is the variety of people at the program. Learning from peers has been wonderful and revitalizing. My cohort group of eight with our varied personalities and styles was a substantial contributor to the value of the week and one of our cohort’s teaching fellows, Bob Hodge gave plenary presentations on informatics and mentoring that I could/would/wanted to have done . . . maybe someday.

The formal program varied as do most. I found our cohort a wonderful experience and the Meyer-Briggs a useful tool on which to organize a presentation. I’m going to do a little more reading about it and maybe develop a column around it.

Meanwhile, A few photos from the week are here.