Jennifer Frank, MD: Crazy busy

I am sure you can relate to the sense of being crazy busy – not just rushing from this thing to that but feeling completely overwhelmed with the multiple professional and personal commitments that line up, seemingly endlessly, before you. I am living this, and it’s not a comfortable place to be.

About six months ago, I was invited to speak at a conference occurring this past weekend. I enthusiastically accepted. It was a great opportunity which I thought would be personally enjoyable and professionally enriching. As the date got closer, the stress of actually preparing for and getting to the event outweighed my excitement. It didn’t help that I was flying out on my husband’s birthday or would be missing my daughter’s dance recital.
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My mixed feelings about making these personal sacrifices for a professional honor showed up in a late departure for the airport, poor concentration for the task at hand necessitating a U-turn to head back home to retrieve my forgotten thumb drive, and a series of mix-ups, hold-ups, and circumstances that had me arriving at the conference about 30 minutes prior to my talk (causing a minor panic attack for the poor woman organizing the conference).

After the talk (which went well despite the inauspicious events leading to my arrival at the conference center), I had time to reflect on my “balance” which was feeling quite out of whack. As I enjoyed the absolutely gorgeous scenery that spread out before, I had time to do something I rarely do – breathe deeply and ponder deep thoughts. I came back to something that has occurred to me on previous occasions when I find myself overwhelmed and underfocused: I am trying to do too much.

I was well prepared for the talk and excited to give it. I had allowed some wiggle room in my schedule, which I did have to use. However, I still arrived with (some) time to spare. My husband, left in charge of kids, house, and pets for the weekend, was supportive of my going, even on his birthday weekend. I was, however, trying to balance my professional role with the guilt of choosing to be away from my family during a time we would normally have spent together (our weekend).

Instead of accepting this as the necessary cost of pursuing a professional opportunity, I was going back and forth in my mind between my role as a physician and my role as a wife and mother, feeling unprepared for one role and guilty about not doing the other well.

In reality, I was upset that I couldn’t have it all – you know, being the star speaker of the conference while also being a perfect wife (home for her husband’s birthday) and mother (clapping enthusiastically in the front row at the recital). In the future, I will need to do a better job accepting that choosing one thing (a speaking engagement or staying home to attend a family event) is often choosing not to do something else. That is the cost of the choice, and consciously deciding to pay that price (or not) will hopefully prevent some of the guilt and a sense of imbalance that can accompany crazy busy weeks.

Telemedicine catching on

Virginia has become the 12th state to require health insurers cover telemedicine services. This includes interactive audio, video, and other electronic media used for diagnosis, consultation, and treatment, according to American Medical News.

The American Telemedicine Association estimates that all 50 states will begin paying physicians for telemedicine services within the next few years.

Telemedicine is often considered in the context of reaching rural or remote areas underserved by certain specialties. But I wonder if it can, and will, become more commonplace as just another way for any physician to interact with patients. In my research for the April cover story, The Future of Healthcare Revealed, telemedicine came up as an option for where care is headed.
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I am also curious what physicians think about it — not as a replacement to the office visit, but a supplement, another option. I just had a follow up appointment with my physician this morning, a short, 10-minute check-in, and even though I live in a city and getting to the doctor’s office is quick, I wonder how much more convenient —and just as effective — a televisit would have been. Could I have just dialed up via web cam and talked with her, saving me the trip? Would it have allowed her to schedule me at a different time, say on her off hours, since she wouldn’t have to staff the office or even come into the office?

During the Future of Healthcare article research, I spoke with a physician participating in online visits, which he called “a common sense, logical step.” It can offer flexibility for doctor and patient alike.

So what are the barriers to telemedicine? Of course, there is the technology. It requires both sides to have Internet access and in most cases a web cam and telephone line. But what about cultural barriers? Are physicians interested in a new model? Considering the low adoption rates of EHRs, would telemedicine be seen as just another high-tech hassle?

Please weigh in on the issue with poll on the right on comment below.

Congress passes another temporary payment fix

Last night, Congress passed legislation staving off the 21 percent Medicare cuts until June 1 — another temporary fix to the SGR-based payment formula.

This vote was the latest of several moves to push back the cuts. Twice this year, CMS has had to step in and tell contractors to hold claims for 10 business days until Congress can pass a fix. The most recent period ended this week.

And once that temporary fix expires again, Congress can pass another short-term solution. Or perhaps it is really time to change the flawed SGR formula once and for all?

Don McDaniel: RECs to the rescue

Many of the readers of Practice Notes are members of or affiliated with small physician practices — physician organizations of 10 physicians or less. As you are now undoubtedly aware, the U.S. government is making a significant investment, as a major component of the American Recovery and Reinvestment Act, to support the adoption of electronic health records.

EHR adoption is still very low in the United States, especially among smaller practices. Therefore, to facilitate the adoption and the achievement of meaningful use of these EHRs among small practices, the Office of National Coordination for Health Information Technology (ONC) has now designated some 60 Regional Extension Centers (REC).
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The mission of the RECs are to help primary-care physicians, small practices, and safety-net providers such as community health centers, rural health centers, and critical-access hospitals, through the provision of consultative support and advisory services to enable successful development of EHR systems, and ultimately achievement of meaningful use.

The REC program funding will create technical extension centers throughout the U.S., and each REC will target approximately 1,000 to 2,000 physicians. They are chartered to be vendor agnostic and to provide unbiased guidance — that is to say that they will not promote any specific application over others — with a goal of helping the smallest of practices manage the work flow and business process challenges of achieving meaningful use.

In total, the federal goal is to assist 100,000 physicians nationally by the end of 2012. Each REC will have access to a newly created, federally funded health IT research center — meant to act as a knowledge management hub and disseminator of best practices to the individual RECs and its clients, the physicians. The RECS will be moving to full operating status within the next six months and a list of each REC, as well as information about the REC program, can be accessed at HHS’ Web site. I encourage all practices to reach out to their assigned REC to ascertain how it can help you on your health IT journey.

Randall Wong, MD: What is SEO?

Search engine optimization (SEO) is a type of marketing strategy used to maximize the placement of your Web site on a search list. It is based upon the relevance of your site, and its content, to the keywords used to generate a search. It is the basis upon which search engines (Google, Bing, Yahoo) rank your web page on a search list.

It is not paid advertising - it's free.

The actual content of my Web site now attracts more visitors from search engines than any other source. As of this morning, 64 percent of the traffic to my blog comes from search engines. Most of my visitors arrive to my page after performing a search looking specifically for health information on retinal diseases.

This did not happen over night. Search engine optimization takes time and persistence. There are three basic concepts to establishing SEO:
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1.Relevance - The content of the your site must be relevant to the keywords, or search terms, used on the search. Google wants to provide Web sites that are highly relevant to the terms used for a search. The search engines want your search to be as successful as possible, that is, they want you to find what your looking for as fast as possible.

The key to successful searches: Relevance.

2. Referrals to your page - Other Web sites, with time, will be linking to your page. Based upon the content of site linking to you and the "anchor text" used to create the link, search engines will validate the relevance of your page. These are also called backlinks.

Anchor text is the words highlighted to create a hyperlink, or link, to a Web page.

Example #1: For more information on retinal detachments, click here.

Example #2: Retinal specialists fix retinal detachments.

Both links get you to the same place, but example #2 uses more relevant terms to guide you. This is noticed by the search engines. It tells Google that my Web site is related to retinal detachments and is a big endorsement with regard to my site's relevance to retinal disease.

3. Refreshed content - The more often your page is updated, the more attractive you'll be to the search engines. This is one reason blogs have become so popular. It's easy to add content to your Web site via blog software.

So, SEO is really about creating credible information. From a marketing standpoint, it is the most concrete way to get your Web page ranked and noticed. There really are no gimmicks. Although you can still pay to advertise your Web site, the only way to gain rankings is to create Web sites that provide relevant information.

From a consumers point of view, say our patients, SEO increases the credibility of the information provided and found on the Internet. It increases the likelihood that our patients may find health information that is really useful to them.

Next week I'll share some of the tools I now use to maximize the SEO on my site.

Gerald O'Malley, DO: On Precious

The other night my wife was working the overnight and I was tired of reading, so I took a break and bought and downloaded the movie “Precious” from the On Demand channel. Since the kids came along I rarely go to the theater — unless the movie has Hannah Montana or a talking fish, I’m usually watching it on my couch.

I watched about half the film but I couldn’t finish it. There is only so much brutality and cruelty and psychopathology that I can take outside of the ER. As I got deeper and deeper into the movie, I recoiled from the hyper-real depiction of violence and depravity.

Finally, as I literally became nauseated, the thought dawned on me – why and I subjecting myself to this? Don’t I get enough of this at work? Don’t I get enough ignorance and hostility and violence from the residents? Just kidding.

The movie was just too good. It was too real.
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To those that aren’t familiar with the movie “Precious” is about a very unattractive and unsympathetic young black woman (ironically named Precious) living with her sadistic, mentally unstable mother in Harlem. Precious is surrounded by ignorance, violence, and antisocial behavior by dysfunctional and psychotic characters including her father, who rapes her repeatedly and impregnates her twice. As the movie opens, Precious is dismissed from her public school because of the pregnancy. A dedicated counselor finds a place for her in a special school for girls with extracurricular obstacles, but every where she turns Precious is berated, beaten, and bullied.

Most of time, despite her enormous size and obesity, Precious is invisible to other people and when she is noticed, she is tortured. The major antagonist is her mother, played by an actress named Mo’nique, who, when she isn’t beating her with pots and pans, is drunk and high, smoking cigarettes and screaming at Precious to forget school and stay home and collect welfare.

After the third or fourth scene of Precious being beaten and seventh or eighth scene of illiterate black characters engaging in irresponsible, immature behavior and substance abuse, I just couldn’t take it anymore. Who wants to see a movie about this crap when I have to deal with this exact same set of problems every time I walk into the ER?

I’m sick of seeing the effects of drug and alcohol abuse on abused wives and children. I’m sick of trying to explain simple concepts of health maintenance like the importance of not smoking crack when you are pregnant to young women (who are generally more interested and engaged in texting while I’m trying to speak with them) that already have two other children from different sexual partners and haven’t read a book or magazine that doesn’t have a menacing tattooed hip-hop rapper thug felon on the cover. Does this have to be celebrated with a movie?

“Precious” the movie does an incredible job of realistically depicting the worst behavior of black inner city inhabitants. I watched as much of the movie that I could stand and I didn’t see a single heroic or even sympathetic character. That is not my experience.

In my years of practicing emergency medicine in the ghetto I have witnessed breathtaking examples of selflessness and honor. Instead of the disgusting and depressing “Precious,” give me a movie about a heroic inner city math teacher or a grade school spelling bee champ or basketball team that beats the odds any day.

Trendspotter: Many ED Visits Reflect Poor Access to Primary Care

By Ken Terry

In Voltaire’s book “Candide,” he lampooned a contemporary philosopher’s assertion that “this is the best of all possible worlds.” Now a pair of emergency department physicians argue in a Slate article that we don’t need to reform our system of emergency care because most ED visits are necessary and, besides, they don’t cost that much. Apparently, these doctors never read “Candide.”

Zachary F. Meisel and Jesse M. Pines state that just 12 percent of ED visits are “not urgent.” However, the National Health Statistics Report they cite says that 16 percent of visits are emergent, 36 percent are urgent, and 22 percent are “semi-urgent,” which leaves a lot of latitude for defining “non-urgent.” Moreover, during the period covered by the study (1996-2006), there was a 32 percent increase in ED visits, while the number of ED visits per 100 people increased 18 percent. So a growing number of people are coming to the ED more often. That suggests that more people are using the ER for primary care.
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The National Health Statistics report points out that 11 percent of all ambulatory-care visits are made to EDs, although those departments have only 3 percent of physicians in the U.S. “EDs provide unscheduled care for a wide variety of persons for reasons that range from sudden cardiac arrest or severe injury to minor acute problems that occur after business hours, or for which the patient is unable to access a primary care provider in a timely fashion. In 2005, approximately one-fifth of the U.S. population had made one or more ED visits within the past 12 months and some subgroups, such as infants, persons 75 years of age and older, Medicaid beneficiaries, and African Americans, had higher utilization rates than others.”

Another key part of Meisel and Pines’ argument is that because ED visits are only a small fraction of total health spending, they’re nothing to worry about. In fact, because EDs are open 24/7, they maintain, "the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors.” I don’t know how they calculate that, but other research contradicts it
In a large-scale study of the cost of non-urgent visits to Minute Clinics (retail clinics in pharmacies), primary-care offices, urgent-care centers, and emergency departments, researchers found that, for treating five common conditions, the adjusted mean pharmacy and medical costs per episode totalled $383 in the ED, versus $159 in the primary-care doctor’s office. Even if the primary-care physicians were paid a bit more for treating patients in off-hours—a rather odd scenario—the ED visit would cost twice as much.

The biggest flaw in Meisel and Pines’ theory is that they don’t consider how many of the emergent and urgent visits to the ED result from a lack of access to primary care. Sure, the majority of ED visitors are insured, but how many of them have comprehensive insurance, and how many shun doctors’ offices because of high copays and/or deductibles? Much has been made of the fact that roughly 20,000 people a year die because of lack of insurance. But people who have skimpy insurance and low wages may also avoid necessary care until it’s too late or until they’re compelled to seek aid in the emergency room.

Finally, Meisel and Pines make an outrageous statement about primary care that I cannot let pass. They say, “Most ‘frequent flyers’—a pejorative term used to describe patients who stop by ERs a lot—tend to be the very sick, those with severe asthma, heart failure, or diabetes. When these conditions flare up, patients do, and should,come to the ER. ERs are designed to take care of acutely ill patients, while doctors' offices are not [emphasis added].”

Now, it’s possible to interpret this statement as meaning that, in a true emergency, these patients should go to the ED. If so, I would not disagree with it. But if the ED physicians mean that primary-care doctors are not equipped to care for very sick patients, I think most generalist physicians would beg to differ.

The fact is that we need more and better primary care so that patients who have chronic conditions are properly cared for, and those who are at risk of developing chronic diseases do not get sick. While we need other kinds of prevention, as well, including better eating habits and smoking cessation, those are not a substitute for universal access to good primary care.