Bitter Pill: Why Medical Bills Are Killing Us


Steven Brill wrote “Bitter Pill: Why Medical Bills Are Killing Us” in Time Magazine, Feb 20, 2013. This 36-page behemoth is actually a quick read, and I think worth the time spent. I never learned this stuff in medical school.

As doctors, we order tests for the “benefit of the patient” regardless of cost. We take this as a badge of honor, that we’re willing to forgo expense to give our patient the best care possible. But it doesn’t stop there. The patient does get a bill for this stuff. They are uneducated consumers. We are uneducated providers. Students and residents, this will become your problem. It will probably become my problem. I think it’s worth taking some time thinking about how this will affect how you practice medicine.

Of course, there are other sides to this story. Hospitals report that they need to charge higher prices to recoup losses from patients who couldn’t pay. Device manufacturers will want to recoup their R&D costs. And we cannot deny the profit motive in inspiring innovation.

Regardless, we should start talking about this now so we can address.

NPR had an interview with the author. If you don’t want to read the 36 page article, take a listen to this: Planet Money – Medical Bills

Also check out the post on Medicare and the Affordable Care Act. As always, feel free to put your comments below.

There’s not nothing more we can do

Ashley Shreeves (from SmartEM) is an EM doctor in NY who took a year to do a palliative care fellowship. Now she practices both. It would, at first, seem to be paradoxical. In EM, we are trained to do something. For us, the end-of-life is a challenge to overcome – not to be met gracefully. This lecture will change the way I approach these situations, I hope you watch. Let me know what you think.


An introduction to Medicare and the Affordable Care Act

Many students have asked me for an explanation of how the health care system works. When we are done with that, we’ll review Consciousness and the Meaning of Life. That’s a big question. So, let’s take it in pieces.

First let’s look at Medicare. This is a government sponsored program that provides health care funding to older people and those on dialysis or disabled.

Next let’s look at the Patient Protection and Affordable Care Act (PPACA or sometimes known as ACA or “Obamacare”). I can’t beat this professionally created video by the Kaiser Foundation.

[slickquiz id=5]

Enhancing pain scale effectiveness

I’ve never really understood the utility of the pain scale. I understand that certain certifying bodies mandate its use and therefore we’re required to use it, but for me, when people consistently rate their pain at 11 or 13 – I never understood how I was to use this.

Seems patients have difficulty with it as well. This gentleman, however, has nailed it.

Sometimes you just need a laugh. Enjoy.

Splint Like a Pro

splint_like_a_proPaul Casey and I were making videos to teach splinting. The lighting was poor, the audio terrible and Paul’s splint application technique was pathetic. So we instead decided to see if someone else has already done this. Luckily someone has. Rob Orman (from the ERcast podcast). It’s called Splint-Like-A-Pro because Rob goes to the ortho techs, who do this all the time – the pros, to see how they do it.


How competitive am I for an EM match?

Emergency Medicine is one of 8 specialities that had 100% fill in the 2012 match. Of the 1,668 positions available, all of them filled. This means you couldn’t scramble into a position if you didn’t match. This doesn’t mean it’s impossible to get a position in an EM residency, but you got to play it smart. Let’s look at the numbers.

Screen Shot 2013-01-23 at 2.39.35 PM

Of US Seniors ranking only Emergency Medicine in their rank list, 5% didn’t match. Of those that had a backup specialty, 12.6% didn’t match.

Summary statistics

summary_statisticsThis table summarizes a lot of the data we are about to look at. The average Step I score for someone matching in EM is 223. For step II it is 234. The average number of programs someone ranked is 10.8.

How many places should I rank?

continguous_ranks_2The way to look at this chart is the bottom shows how many places a student ranked, the blue line represents US Seniors (ignore the green one). The more places you rank, the more likely you are to match (obviously) People ranking 16 or more programs all matched.

How good do my Step I scores have to be?

usmle_step_1This graph shows probability of matching against USMLE Step I scores. So you can see, that even with a score of 200, you have an 80% chance of matching SOMEWHERE. Maybe not where you want, but somewhere.

How good do my Step II scores have to be?

usmle_step_2For Step II, they don’t have a similar probability graph but a chart. Still you can see the same information here. If your Step II score is between 181-190, you have more of a chance of not matching than matching. Between 191-200, you have a 66% chance of matching. Obviously the higher your score, the more likely you will match.

If you want the full data, you can look at the Emergency Medicine relevant data at this link.

What do residency directors look for in their applicants?

Hello prospective Emergency Physicians. Dr. Casey and I have created this note to help maneuver through some of the documents that the NRMP (National Residency Matching Program) put out, specifically in regards to matching in Emergency Medicine. Our hope is that this can answer some of your questions before we meet, so we can spend our time together answering questions pertinent to your specific situation. In this first post, we’ll look at the Results of the NRMP Program Directors Survey 2012.

The way I would interpret this data is to understand what program directors are thinking. You can adjust your approach accordingly. If they don’t value your personal statement so much, now you have permission not to obsess about it. Focus on what does matter.

What do program directors look at to grant interviews?

looking_for_in_interviewees_1looking_for_in_interviees_2The first two charts (you’ll have to click on them to see bigger versions) reflect what program directors think are important in deciding whether to grant an interview. By far the thing most PD’s (program directors) value are letters of recommendation from someone in Emergency Medicine. Also important are your clerkship grades, your EM grade (especially if that’s an honors) and an audition elective. It’s also important to note what’s not as highly valued: second languages, post-interview contact and membership in the Gold Society (hmm, what does that say about our humanism?).

What goes into ranking applicants?

factors_in_ranking_em_applicantsIn determining who to put at the top of their rank lists, an audition rotation at that institution has the greatest weight. Similarly, an away rotation at another institution is also prized. A second-visit after the interview, your personal statement, interest in an academic career and the Humanism society (man, we’re heartless) are at the bottom of the list.

How important are board scores?

step_one_scoresstep_two_scoresI don’t think it’s a surprise that board scores are important. All places require a Step I score and most require Step II. If you fail either of these tests on the first pass, a large number of these programs will not consider you (or only rarely do so). The other way to spin this is that there are a few programs that will.

What board score do I need?

step_scores_and_interviewsThese next two charts show two important pieces of data. At what score will I not get an interview and at what score am I almost guaranteed an interview. The box plots represent interquartile ranges, meaning the top line is the 75th percentile and the bottom line is the 25th percentile. So for Step I, with a score of around 200, seventy-five percent of the program may not consider you for an interview. If you rock a 250 on Step II, 75% of programs would very likely give you an interview.

How many interviews do they grant?

applicants_interviewedOn average, a program will get 719 applicants, interview 132 of them, rank 117 and match only 11. This corresponds to 39% of applicants being rejected for an interview and 57% being granted an interview.

So take this for what it’s worth. It’s at least a starting point for discussion. Feel free to ask any questions or contact me or Dr. Casey. Here’s a PDF of these charts if you’d like.

Radiolab: End of Life Care

radiolab_logoThere was an amazing piece on the Radiolab podcast this week (Jan 15, 2013) on perceptions of end-of-life care. This is an issue that we face in the Emergency Department as we see many patients who present in their last minutes. This may be an acute exacerbation of a chronically ill person or an acutely injured patient.

Our instinct and training is to “do something,” so it is hard to sit on the sidelines and do nothing. Sometimes the family or patient can give us an indication of what their wishes are. Sometimes we are faced with the decision of discontinuing a resuscitation which may be pointless.

Listen to the podcast and feel free to comment below. There are no right or wrong answers, just a discussion. Let me know what you feel about it.;containerClass=radiolab

Article: End of Life Issues in the Acute and Critically Ill Patient
Blog post from doctor mentioned in podcast: How doctors die

What is your learning style?

In medicine, we are presented with information to learn in many different ways.

  • Reams of journal articles and text book chapters
  • Flowcharts and anatomical atlases (atli?)
  • Managing a complicated patient on the first day of your rotation
  • Paper cases allowing you time to reflect and digest information

Regardless of how you learn best, you’re going to get information in ways that work for you and many ways that don’t. You’re going to need to adapt. It pays to know how you learn so you can engage in strategies that help you deal with situations that don’t match your style.

There’s a great 40-question test by Felder and Silverman to determine one’s learning styles. Here are my results after taking the test. Apparently, I’m quite unbalanced.

Results for: Rahul Patwari
ACTIVE     11  9  7  5  3  1  1  3  5 [7] 9  11 REFLECTIVE
SENSING    11  9  7  5  3  1  1 [3] 5  7  9  11 INTUITIVE
VISUAL     11 [9] 7  5  3  1  1  3  5  7  9  11 VERBAL
SEQUENTIAL 11  9  7 [5] 3  1  1  3  5  7  9  11 GLOBAL

I like to sit back and think about things, then make colorful diagrams, sketching out connections and sequential steps. Apparently I can’t learn by listening (my mom could have told you that). Yet there are tactics I can use to learn well in a lecture.

I recommend taking the 5 minutes to figure out your learning style then look here to see how to adapt to other styles. What styles are you? How have you adapted to succeed in medicine? Put your comments below.