Monday, April 20, 2015

Poisons and Productivity

The pharmacist in the ED sets a packet of paper in front of me, proclaiming with more than a hint of irony that this is from the Poison Control Center.  She says it like this because as far as he can tell, the Poison Control Center does very little besides telling people to go to the ER and sending faxes, and has nothing at all to do with the real work of patient care.  The Poison Control Center used to be a thing, though...tucked way deep in the bowels of most children's hospitals, they maintained a mythic quality as the repository of all toxic expertise which they would deign to share with the poor mortals when asked on bended knee.  However, as more ER residents rotated through these hospitals, we saw the Poison Control Center for what it was, a technician in a windowless basement room playing solitaire waiting for someone…anyone…to call so they could read to them off a microfiche (yep, I'm that old) whatever the latest case report was from the Lesser Mongolian Journal of Yak Toxicity.  Eventually, the docs figured that we can read a microfiche, too; and as time elapsed we could do one better and look up things on the internet.  Plus clinical overdose management has progressed remarkably, and in many ways has retreated from some of our more aggressive care of days gone by.  No more pumping stomachs, no more ipecac-barfing, no more drinking the charcoal and pooping out briquets.  (Pro tip:  They still need lighter fluid, but watch out for the pockets of methane. They explode.)  I actually miss those days; as a true believer in the occasional benefits of punitive therapy, I thought it sometimes did a word of good for those people who were using pretend overdoses to manipulate others to go through a little discomfort themselves, perhaps as a reminder that actions have consequences.

Aside from a few specific antidotes, overdose management is essentially protecting airways, stabilizing vital signs, and managing complications, exactly like it is in any other patient.  It's all pretty basic stuff.  So now all the Poison Control center has to do is tell people to go the ER and fax things telling us that Yak spit is highly toxic to...well, nobody, but that there was a case report of a Westerner who got bit by a Yak in 1974 and was so afflicted he abandoned his wife and family and lived in a yurt for three years before resuming his role as the second-best insurance agent in Chillicothe, Missouri.  So we should probably admit the patient for observation just in case this occurs.  




One of the trends in emergency medicine is to reimburse physicians based on RVU's.  An RVU is a relative value unit, and it was created to quantify the relative work load, experience, knowledge and time commitment related to a particular medical procedure or patient encounter. The idea is that the harder you work, the more patients you see and the more RVU's you generate.  It's a variation of fee for service that basically means you eat what you kill.  And it's a radical departure from traditional emergency medicine pay which is based on a hourly rate.  

While I understand the desire to drive productivity through incentivizing physicians, I'm not sure that the RVU system is right for emergency medicine.  The RVU system works best when a physician has control over his patient population and daily workload.  In that event, you can choose to work harder, faster, and drive up more RVU's. The ER doctor, however, cannot control his patient load.  People either show up at the door or they don't, and you can't control for the complexity of the patients.  There is every chance for a doctor gets penalized because it's a slow shift or because critical patients or social catastrophes (and there's a lot of those) decrease your overall productivity.  But I also think the RVU system can act as perverse incentive.  On one hand, it encourages slipshod medicine, as the goal is to generate more RVU's by running patients through the system as fast as you can. Things can get missed, patient education can be compromised, and patient satisfaction falls as they feel "rushed" through the system.  On the other, it drives up costs, as one of the ways to escalate the RVU's without taking more time with the patient is to order lots of x-rays, lab studies, and consultations, sometimes by protocol even before a provider actually sees the patient.  

Those proponents of the RVU system might point out that a strict hourly salary promotes lethargy.  Why should someone work hard, or harder, if they're getting paid the same amount no matter how much effort they expend?  The answer to that, I think, is something as simple as professional pride.  Nobody wants to be known as the slowest doc in the group, and even less as an outlier even if your pace is off.  It irritates your colleagues who, at the change of shift, walk into a full waiting room and an ER full of half-done checkouts even on good days.  And if the behavior persists, eventually the group finds its’ way without you.  

I should also confess that there is a "sore loser" component to my complaints.  Reimbursement rates for RVU's were determined the same way all reimbursement rates were calculated; through prolonged lobbying, begging, and cajoling.  When the system came out, the clear winners were the more procedure-based specialties.  Which is why, with the same four years of training, an eye doctor can charge a small fortune for spending twenty minutes removing a cataract, while I get a fraction of the dollars for spending an hour with a critical patient saving their brain, heart, lungs, and everything else that makes that eyeball possible.  Not that I dwell on it, at least not too much.  My comfort is that primary care specialists (family physicians, pediatricians) have it a lot worse.  

(This reminds me of an entire sequence of jokes about doctors and money, courtesy of Drs. Kevin Dishman and Frisco Morse:  

How do you hide a dollar from an internist?  

Hide it under a wound dressing.

How do you hide a dollar from a surgeon?  

Tape it to the EKG.

How do you hide a dollar from an orthopedic surgeon?  

Tape it to the chart.

How do you hide a hundred dollar bill from a pediatrician?

It doesn't matter.  They've never seen one.  

Okay.  maybe you had to be there.)




I had just gotten back from a meeting talking about RVU's when the Poison Control paperwork landed on my desk.  The patient had ingested something called Krud Kleener, which turned out to be a weak alkali, kind of like bleach.  Nobody dies from bleach.  (I've heard rumors, though, that everyone who drinks bleach gets whiter and starts to channel Neil Diamond.  I am, I said, to that damn chair.)  

Now, if I had been an RVU guy, I would have gotten a bunch of labs.  I might have given a dose of charcoal as well.  Maybe the stuff could have eaten though the esophagus or stomach and caused a perforation. I can look for that with an x-ray, or maybe even a CT scan. I could toss an EKG into the mix as well.  The fact that none of this would have been supportable by the medical literature is besides the point. Given a small amount of medical knowledge and a smattering of latin terminology, the enterprising clinician can justify anything. 

But I don't do that.  I don't do it because of any particular drive towards cost-efficiency or the practice of evidence-based medicine. I don’t because I'm lazy, because I know that nothing I could do is going to make any clinical difference, so why bother.  I also don't do it because I know there's got to be a good story here, because the patient drank from a bottle (brought to the ER)  most clearly labeled KRUD KLEENER, and I'm the kind of guy who's willing to kill his productivity to hear the tale.  

It turns out that unbeknownst to me, locked inside my HVAC-sealed workplace cocoon, it had been a hot day outside in the real world.  The kind that makes people who are standing outside watching a yard crew cut weeds want to drink something.  Anything, in fact, that looks like water, even if it says Krud Kleener on the bottle set aside in the corner of the garden trailer, because she was pretty sure that the crew had put extra water in there because, as you know, it was a hot day.  

At this point, I've already lost some RVU's by taking the time to hear the story.  So why not go ahead and cut my productivity to the bone with a little non-reimbursable patient education?  A little Socratic method, please.  

"I think you'll be just fine.  But what have we learned?"

"Well, it's not really that guy's fault for me thinking it was water."  

A patient pedagogical moment. "No, let's try that again.  What have we learned?"  

"That I should have stopped after the first mouthful tasted bad?"  

"True, but what have we learned today that will keep us out of trouble tomorrow? What should we do if it says KRUD KLEENER on the label?" 

There's a look of puzzlement, and then enlightenment breaks out on her face like the sun after a summer afternoon storm.  

"I don't drink it!"  

Another successful patient encounter, another crisis averted.  But done way too cheaply. No RVU's for me.  Should have ordered a CT scan.




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