Health Care and the 20 000 Bruise A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old sons head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospitals billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasnt indicated and didnt even occur.

What he didnt address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesnt this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctors office?
Why is the charge for a trauma team activation $10,000?

Read More..

True grit

In case you havent noticed, a hot new topic in education is "grit." In order to reduce the long-standing 20% attrition rate of surgical residents, some say we should select applicants who have more grit or conscientiousness.

A recent paper in Surgery reported residents who dropped out of programs had decreased levels of grit as measured by a short-form survey. But due to unexpectedly low attrition rates in the surgical programs participating in the research, the study was underpowered to show a statistically significant difference in outcomes of high-vs. low-grit individuals.

Its hard to argue with the premise that choosing applicants with high reserves of grit might lead to better retention and performance of residents.

I blogged about this three years ago in a post called "Harvard says train residents and medical students like Navy SEALs."

Unfortunately, identifying who has grit will be much more difficult than simply testing those applying for surgical residency training.

Below is the eight-item grit survey, which is scored on a 1 to 5 Likert scale.

1. New ideas and projects sometimes distract me from previous ones
2. Setbacks dont discourage me
3. I have been obsessed with a certain idea or project for a short time but later lost interest
4. I am a hard worker
5. I often set a goal but later choose to pursue a different one
6. I have difficulty maintaining my focus on projects that take more than a few months to complete
7. I finish whatever I begin
8. I am diligent

The survey is rather easy to "game." You can take it online and see for yourself. Figuring out how to achieve a high grit score should be obvious. My grit score was 5 making me grittier than 90% of the US population.

You can avoid any uncertainty about passing the test by reading the paper which conveniently spells out which answers result in a high grit score. If the word ever got out that applicants to surgery residencies are being screened for grit, you can bet that only those with high "clueless" levels will score poorly. At least the clueless would be weeded out.

Attempting to assess grit in an interview would be equally hard for the same reason. Picture this conversation.

Program Director: Do you finish what you start?
Applicant: No, I dont.
Program Director: Are you a hard worker?
Applicant: No, Im not.

Who is going to answer grit-related questions in a non-gritty way?

Heres another issue.

Despite rigorous background checks and thorough testing of physical and mental qualifications, some people selected for Navy SEAL or astronaut training fail to make it through.

Compare that to the process of selecting surgery residents, which involves sifting through several hundred applications for an average of four positions per year. Medical school grades and USMLE scores dont predict resident performance or success, nor do deans letters and letters of recommendation from mentors.

Most programs conduct two or three interviews of 40 or 50 candidates for a total of maybe 45 minutes. Even if one luckily identifies a gritty applicant, she may not end up in the program. Because of the way the matching algorithm favors the applicants choices, a program will almost never end up with all of its top candidates anyway. Its a bit of a crapshoot.

What can we do if we match applicants with average or low grit? An article in the Huffington Post says we dont know how to teach people to be more gritty. I think its like common sense—a trait that cannot be changed or improved.

Assessing applicant grit levels might help, but the short-form grit survey is probably not the answer.

Read More..