Monday, April 21, 2008

Odds and ends

1) From the American College of Surgeons "Surgery News" April edition: Future Surgeon Shortage Predicted. Interesting. But is it valid? Where exactly in America are we anticipating a "shortage"? Topeka, Kansas? Fargo, North Dakota? Truly, there will never be a shortage of general surgeons in places like Chicago and New York and San Francisco. Never. Guys are clawing each others eyes out to get every last gallbladder and hernia they can. Moreover, there's another study from the JACS in April which studied workforce projections for hepato-pancreato-biliary surgery. According to this study, the current levels of fellowship training will result in an excess of subspecialists in that field by 2020. What does that tell you? More and more chief residents (over 50%) are opting to pursue further fellowship training prior to embarking on a career. Training more surgeons, expanding residencies, or building more medical schools is not the answer to the so-called shortage. You can train all the residents you want, but if most of them ultimately decide to become vascular surgeons, or CT surgeons, or plastic surgeons, or "laparoscopists", then you aren't doing society any favors. We're trying to sub-specialize general surgery to death. That won't be a problem in the large metropolitan areas with multiple academic institutions because you'll have your colorectal guy, your foregut guy, your bariatric guy, and your hernia man, but in the rural and semi-rural communities across America, it's going to be a gigantic problem. The general surgeon who can do breast and bowel and endocrine and advanced laparoscopy is going to be in great demand. If American residency programs don't provide them, be assured that hospitals will seek qualified surgeons from somewhere (the foreign talent pool).

2) Any reason why GI needs to be consulted on a bowel obstruction? Yeah, I don't know either. Good way to drive up costs. If I'm wrong, please let me know in what way. You don't need two specialists to come by, examine a belly, put in a nasogastric tube, check abdominal films, and decide whether or not the patient needs an operation and when. Especially when one of the specialties doesn't actually do operations...

3) The controversy over "never events". Cigna recently published a revised list of "potentially non-reimbursable" events that has the medical blogosphere all aflutter. Me included. Apparently, urinary tract infections from indwelling Foley catheters ought NEVER to happen. Nor is it conceivable that the little old lady on the floor one week after abdominal surgery could lose her balance, fall and break a hip. And central lines aren't allowed to get infected anymore. Decubitus ulcers in demented nursing home invalids who swing by the ICU for a short stay will no longer be accepted. The sickening thing is that this is all done under the guise of "improving patient care". In reality it's about controlling costs. So I don't get paid when I get consulted to debride a rancid sacral ulcer that's been there for probably a year? ID doesn't get paid for their consultation on an elderly patient with urosepsis?

4) Go Cavs. Deshawn Stevenson maybe ought to re-think the wisdom of calling Lebron "overrated".

5) The Tribe can't hit. CC Sabathia can't find the plate. Could be a long season for the Indians..... so glad I got a ticket package.

2 comments:

platensimycin said...

A reasonable follow-up question is: what can we do about the awful medical insurance atmosphere we face today? Traditionally, those with experience gradually move up the ladder and eventually make/influence/oppose decisions as a member of the administration. They are armed with the experience, credential, position and perhaps wisdom to make wise calls on tough, and at times, contradicting issues. It is still the same today, or do decision makers nowadays come straight out of legal or financial training and dictate protocols that perhaps they can’t fully understand? Surely a chief of surgery would know more about central venous access than a legal or insurance underwriter would. Perhaps there are more underlying causes that compound on this issue than greed alone....

make mine trauma said...

Cigna sucks anyway, at least for me. As a non-md first assistant, they won't pay for anything. They will only reimburse MD assists, not sure how well they reimburse primary surgeons. I can see them jumping on the Medicare bandwagon (Medicare started this list, no?)to screw a few more providers.