Is there a trial lawyer in the House?

OK, I know I promised I’d continue with “Who are these people?” I also promised myself that I’d leave the economics of physician compensation out of the column. However Ann Coulter, a lawyer, has made some important points regarding the relationship beteween physicians and the government.

As a physician with a law degree I think I am qualified to comment on both professions and the relative training. A three year law degree delivers the graduate into practice sooner than a four year medical degree. Most lawyers have very little formal post-graduate training whereas essentially all physicians need at least three years of additional training in order to practice. In essence law remains a three year curriculum while medicine has evolved into a seven year curriculum. Most of medical training is physically as well as mentally demanding. When law students stay up all night it’s generally by choice. Medical students are compelled to do so. The well being, or even the life, of patients is at stake every day.

I practice in west Texas. The Medicare reimbursement rate here is about $75 per hour if I’m really lucky. It can be as low as $45 per hour. In contrast my personal attorney charges $400 per hour- she doesn’t give discounts. She doesn’t take insurance. She’s more expensive than some but cheaper than others. My plumber gets $80 per hour. My electrician- $88. My physician gets whatever he can squeeze out of the insurance company. After all the insurance company has to support stockholders and pay a multi-million dollar bonus to the CEO. The insurance company makes money by denying care to subscribers. The federal government has chosen to balance the budget at the expense of patient care rather than redirecting the billions of dollars of “pork” that legislators feel necessary to insure their re-election. Voters may not be able to get decent healthcare but legislators certainly are insuring their future.

The government doesn’t bargain. The government makes it onerous to opt out of the Medicare system. Every physician, except a few specializing in cosmetic surgery on a cash basis, is working harder and being paid less. This year, unless the President intervenes- and he said he won’t, Medicare reimbursement will decrease an additional 10%. I suspect that the older patients depending on Medicare are not planning to be 10% less sick this year. What are the chances that congress will consider balancing the budget by giving themselves a pay cut? Since many of them are already independently wealthy they may not even notice the decrease in pay- but that won’t cause them to be responsible.

I think back to the time when my children went to college and began thinking about their careers. I told them I would not pay for medical or law school. I urged them to study something useful in college, learn to do advanced mathematics, read and write English extremely well, and learn to speak Spanish, Japanese, or Arabic. I’m glad I discouraged them from medicine. They’ll be happier. They might make more money- especially if they go into plumbing.

If this disturbs you, and it should, you need to protest reductions in payment to your physician. Check you “explanation of benefits” (EOB) after each visit. Ask you physician if (s)he receives bonuses for denying care or cutting costs. Complain liberally to your employer, legislator or the state medical board.

It’s your healthcare. If you don’t take responsibility it may not be there tomorrow- or worse it will come from a civil servant with all of the efficiency of the postal service and all of the compassion of the IRS.

Who are these people?

Most of us have been patients. If we’re really lucky it’s only been well care, check ups or the occasional minor illness/injury. The less fortunate have serious or chronic illnesses or have been the recipients of hospitalization or major surgery. In any case you’ve probably met numerous people besides your doctor who said they’re there to help. But who are they? What do they do? Do you need them? In the next few issues we’ll look at them more closely.

Nurses
The last 50 years have seen an enormous expansion of nursing duties and scope of care. All nurses in all states must have a license. Licenses are issued by states after successful completion of a prescribed course of study at a qualifying institution. What does that mean? They’ve all been to some school in addition to a high school diploma or equivalent. Many nurses have advanced degrees, special qualifications, or advanced skills. Some of you have met the nurse practitioner in your primary care physician’s office.

Registered Nurse
The registered nurse or RN is the basic diploma or degree for nurses. Many states also permit LVN (licensed vocational nurse) or LPN (licensed practical nurse). These other nurses frequently have limited scopes of practice and act as an “extender” for the RN. When choosing a hospital you should always ask what the nurse to patient ratio is for each shift. Also you should ask if the nursing staff is all RN or mixed RN/LVN. If the staff is mixed then the important ratio is RN to patient. The reason is that many states or hospitals limit LVN care. LVNs fequently cannot administer some medications. If the RN is the only one who can administer a particular medication that you need, you may have to wait until the RN takes care of several other patients with similar needs. It may not be bad but if you’re waiting for pain medication that could be a pain couple of hours.

Several years ago I worked at a tertiary care hospital. The RN was overloaded and way behind schedule so she allowed an LVN to hang a particular medication that she was not permitted to hang. The LVN made the mistake of hanging an intravenous medication for a different patient. Additionally, the medication was run into the patient’s epidural catheter instead of the IV resulting in a massive overdose. The mistake was recognized and treated appropriately with no adverse effects.

Such occurences are uncommon but dangerous. You should always question any medication administered.

Advance Practice Nurses
Nurse practitioners are one of the most common form of advance practice nurses. Another comon form is the certified registered nurse anesthetist (CRNA). Each of these nurses have a nursing degree, nursing license, advanced training, and special state rules defining an advanced scope of care or specialization. The degree of practice latitude that an advance practice nurse is permitted varies by state but generally requires some form of physician association or supervision unless the nurse is acting under an approved protocol (again this varies widely in some cases).

If your physician uses nurse practitioners or your anesthesiologist uses CRNA’s you should ask the role that each advanced practice nurse plays as well as the limits placed upon him/her in the specific context of your care. Some primary care physicians insist that each patient be seen initially by the nurse practitioner- particularly for primary follow-up care. Patients should be aware of the limitations and discuss the implications with the physician.

Patients should also interview the nurse practitioner or CRNA. Reasonable questions include: How long have you been doing this? How long have you been a nurse? Does the doctor check your work or confirm your findings and conclusions? Is care protocol driven? Each of these questions are appropriate for you to ask your physicians therefore they are appropriate for any health care provider. No reasonable provider should be offended by these questions. If they are- you need a new provider.

Your nurse practitioner can be a strong ally in your health care. (S)He can facilitate referrals. (S)He generally can expedite prescription refills, lab tests, and eliminate the need for some follow-up visits. Once you establish a good relationship with your nurse practitioner treat it like a doctor-patient relationship.

Finally, remember that nurses, like doctors, make mistakes. Question everything. The need for lab work- who will interpret the results and how? How will the results change therapy? When the nurse in the hospital brings medication make sure it’s for you. Make sure the dose is correct. Learn what each of your medications look like and make sure it’s the right drug.

Next time I’ll address all those young looking people who are called doctor- residents.

Your health care is yours. Take control.

Welcome to Safer Health Care

This is our first blog post. Safer Health Care is a group effort of the principals of The Aegis Firm, a health care consulting firm.

The idea for The Aegis Firm and this blog first arose when I was in law school. It bothered me that lawyers all take a course in professional responsibility. In fact, to get a license a law school graduate must pass a standardized exam in professional responsibility. Medical schools and state medical boards have no similar requirements. That struck me as wrong. Since then I have spent several years teaching professional responsibility to physicians. An integral part of physician responsibility is placing the patient’s needs first and maximizing patient autonomy through education and shared decision making. Also critical is full disclosure and the abandonment of the traditional paternalistic approach to health care.

Soon to come will be tips for getting the most of your relationship with your physician, dentist or other health care provider. Your health is really in your control. I will help you navigate the health care waters and avoid becoming a health care statistic. Aegis partners, as well as registered users, will include clinical vignettes with commentary to serve as illustration.

The Aegis Firm provides services to health care organization as well as individual physicians to improve patient safety and relationships, regulatory compliance, risk management, and security.