Healthcare Administrator Salaries and the French Fireplace

June 5, 2009

stress salary

A few days ago, I had the great pleasure to visit some good friends from the hospital for lunch. They are good, hard-working people; salt of the earth. It bothered me how hard they work and how they seem to get so little back for their work, and I mentioned that to them. It led us into an interesting conversation about how much the admin people are making at our local community hospital – I think I hurt my jaw when it hit the floor.

I am not naive when it comes to the outrageous salaries that health-care administrators (CEO’s, CFO’s, COO’s and all the other acronyms they make up to take more money for nothing) seek to justify to themselves, but most people tend to think of these overblown salaries as belonging to Wall Street types in big cities; not your run of the mill smaller town.

So, I was quite surprised to learn that the CEO at our hospital pays himself close to a half million dollars per year. All while cutting nursing hours, chastising docs about overtime hours and outright terminating other direct patient care personnel positions for “cost savings”. The CFO also gets a healthy paycheck, closer to a quarter million though. He once told the hospital staff that they always have to go for the best in patient care, kind of like when he couldn’t decide on importing an $80,000 fireplace from France or buying an American one for under 10 grand. He decided that he should go for the “best” and went ahead and imported the French one in the end. He probably should have ordered a mail-order brain and conscience while he was at it.

This prompted me to look into the whole issue of the hospital administrator fleecing of America. I found many intriguing details that just nauseated me in general, but none better then the following concise post written by Dr. Ira Kirschenbaum on his Mad About Medicine blog. I will quote just one paragraph here for your benefit:

… the next time you want to argue with your Primary Care doctor’s front desk about a $5.00 co-pay, remember that he makes an average of $149,000 per year. On the other hand — using United Healthcare as an example — your insurance company paid their CEO — one man — [324 million dollars] over a recent five year period.

He then goes on to list 23 health-care CEO’s salaries – mostly those of insurance companies and drug manufacturers – and their published 2005 salary as well as 5-year combined income. The “poorest” guy in the bunch, James Tobin of Cardinal Health, made “only” $1.1 million in 2005, but he had a good 5-year period over-all, making $33.5 million (or just under $7 million/year). Poor James, what ever will he do to keep up with the Joneses?

Inevitably though, discussions like this lead to some people praising the wonders of capitalism and warning against the evil of “socialism”. At the end of the day though, it is balance and moderation which saves a society.

Our hospital will certainly go down, as it eventually must with these crotch stains at the helm. At that time, I seriously doubt that the hundreds of people out of the job will be giving a damn one way or the other about political ideologies as they join the masses screwed out of their job by corporate greed as they try to figure out how they will put food on the table.

Add to Technorati Favorites


I’m Feeling a Little Anxious

May 31, 2009

A rare thing happened in my ER last week when two major traumas were brought in after what appears to have been a drug deal gone bad. I was not working when they came in, but got involved two days later when the prime attacker came into the ER for “anxiety and trouble sleeping“.

J tells me when I walk into the room, “You probably heard about what happened earlier this week right?” I had certainly heard bits and pieces from some of the nurses but never got the whole story so I told him I wasn’t sure what he meant. So he gave me his version.

Well, I was gettin together with some of my friends who were buyin some cocaine and other stuff from me when they started arguin with me and for no reason at all grabbed me and started poundin my head against the pavement. [perps always seem to be violent for no apparent reason at all don’t they?] And then they pulled a shotgun and a knife on me. I tried to calm ’em down but they were real angry [coke heads angry? nah, I don’t believe you!] so I pulled out my knife and we scuffled and they ended up comin here to the ER and were flown out …”

What I knew had happened was that two people had come code three by two EMS units with “their intestines hanging out” from knife stab and cut wounds. They were stabilized rapidly and moved on via helicopter to the nearest trauma centers. The attacker, the one who was my patient presently, was unhurt and arrested. He had gone directly to jail but apparently was released on bail somehow so he could come and visit me. Police had searched his house and taken all of his drugs – an assortment of meth, cocaine, benzodiazepines, narcs and other drugs as well as weapons.  That left him in the precarious position of being unable to get high.

So I told him, “Sounds like you’re pretty skilled with a knife from what you’re saying.” He replied, Not really, it was all in self defense” [its always self defense isn’t it?]. So he continues, “I just need something to help me sleep and to calm me down.”

I could understand. The guy was facing some serious jail time for attempted murder x 2, drug dealing, weapons charges and probably some other bad stuff – he couldn’t get high off of his supply and neither could his wife, who was apparently outside raising hell in the waiting room because she too was “anxious”.

And then his mom, who looked like she belonged in WWF, shows up. I guess you could say that he had some reasons to be anxious.

I didn’t buy into writing him any more drugs though and gave him a shot of Geodon to get him the hell away from our hospital. He may be anxious, but as they say, “you make the bed, you sleep in it.” I doubt he’ll be getting anything in jail to calm his nerves so might as well start getting use to it now right?

Add to Technorati Favorites


The Radiologist Examined a Patient!

May 30, 2009

Those of us in the medical field know the radiologists – the doctors who read xrays, CT’s, etc. – usually sit in their dark room all day and read films, often times with CYA statements at the end of their official report that say something like, “_____ cannot be excluded, and so a [another imaging study inserted here] would be recommended …”.  The type of person who typically goes into radiology is a person who doesn’t much like dealing with other people, and so they only “see” patients when, and if, they have to do a procedure, or if they pass them in the hall. It is rare that I even have the chance to discuss my clinical exam with a radiologist since they don’t usually seem to care about our seemingly worthless thoughts.

But in my hospital, I have the great honor (doesn’t always feel that way) of working with some of the smartest doctors in the world when they moonlight here away from their Ivory Tower. Their hospital is internationally recognized as one of the best medical centers in the world. Among this distinguished group are the radiologists that will moonlight here on weekends. I have to say that some of them have their nose so stuck up in the sky that we only look like ants to them, and that is how they speak to us. But something cool about medicine is that experience almost always trumps medical training. There are many nurses I would rather have treat me that some of doctors I have had the horror to meet.

So, last week I came into work and my first patient was a poor old woman who was run over accidentally by her husband with a farm tractor. I called to request a CT of the chest, concerned about flail chest and significant thoracic injury. The Ivory Tower radiologist balked at my request and stated with great annoyance (how dare I interrupt his computer game) that he would read it, but that he thought it was totally unnecessary. He felt a simple x-ray should provide adequate information. I responded by saying innocently that I was unaware that x-rays would show vessel damage since after all there are some big pipes running through the chest (aorta, IVC, subclavians and oh, that darned thing that keeps beating).

He made getting the CT a chore as well (some sort of punishment I suppose) by having the techs refuse to do it until I checked her kidney function. It was a trauma! Why should I wait for kidney function? But they insisted.

He humbly called me back an hour into this poor woman’s ER course to tell me, “Man, this lady’s really messed up!” I asked if that was his medical diagnosis.  The “official” report was that she had broken 10 ribs on one side, had a collapsed right lung, and bilateral lung bruising. Nah, we didn’t need that CT now did we? I resisted the urge to rub it in and focused on taking care of the patient instead.

But every now and again, we do get an exceptional resident from the Ivory Tower. This weekend, I have the true honor to work with one such radiologist. Professional and personable, so much so that I am almost convinced that he is not a radiologist by training. Maybe he’s like that guy from Catch Me If You Can? He doesn’t call us to give us reports, but comes in to see us in person on almost every case in order to discuss the case and provide his report. This not only makes him courteous, but way smarter than the other radiologists because getting the clinical backdrop is a very good way to not miss something important. When you understand in detail why the test was ordered , it helps you zoom in on the area of concern with a different perspective.

But then he did the unthinkable. Our stellar resident actually went and examined the patient! I don’t think that in all my years of medicine I have ever witnessed such an event. I thought radiologists had lost the art of examining patients by the time they finished their internship, but this guy proved us wrong. Kudos to you my friend and maybe you will be an inspiration for the others in your field to come back down to earth.


When Funerals Go Bad

May 26, 2009

While at work yesterday, I overheard the ambulance going out to a call at a graveyard. Now, I personally like to give everyone at least one round of ACLS no matter how long they were down prior to arrival, but I think you have to draw the line somewhere right? In the end though, it turned out to be nothing. It did remind me though of one bizarre funeral that I received some clients from once while working in the South.

Family members had gathered for the funeral of someone who had died young. While the eulogy was being given, one of the deceased man’s brothers couldn’t contain his grief any longer and tore open the casket, dragging his dead brother out in front of the whole family so he could hold him. Needless to say, people started fainting, screaming, crying and the rest were just frozen in horror at the macabre proceedings.

I received two people via ambulance from this funeral with complaints of anxiety and fainting. Nothing a little bit of Ativan and a lot of counseling couldn’t handle though. I never did get to meet the hulk who ripped open the casket though. And that is a very good thing.

Add to Technorati Favorites


Death and ATV’s

May 24, 2009

Sorry for the recent absence, but I’m back now. And what better way to get back into gear after being on vacation than to work Memorial Day Weekend! I should have my head examined.

ATV – All Terrain Vehicles, or as I like to call them, four-wheeled death machines. I hate ATV’s and wish they would be banned. I have seen too many tragic consequences from them and think the risk-fun ratio is just way too high. I like to have fun as much as the next person, but when people start dying, we need to take a time out and reassess. My first bad patient experience was my first year out of residency when the respiratory therapist that i work with brought her son in DOA (Dead on Arrival) after he was riding behind his brother who hit a tree. Unfortunately no helmets were worn. This weekend though brought on more sadness.

23 year old woman, drunk, riding an ATV at night runs into a barbed wire line at speed. The wire cut into her belly, removed the right kidney from its blood supply (a big hose), lacerated her liver and spleen and cut some intestine. She went immediately to surgery and bled to death on the table.

30 year old woman, majorly drunk, riding an ATV in daylight and rolls it in a field. She suffers multiple spine fractures, lacerated spleen and liver as well and dislocates her hip. Ouch! She survives surgery, but quality of life after this accident will be questionable. She will have pain everyday for the rest of her life I imagine.

Please, if you read this post and either ride an ATV or know someone that does, make sure they always wear a helmet and that they don’t drive after even one drink. If you can send the whole thing to a junk heap to be crushed that would be even better. You can have fun in far safer ways. Have a safe weekend please.

Add to Technorati Favorites


Contributing Factors to the Current Physician Shortage

May 16, 2009

As early as 2005, predictions were being made of a coming shortage of medical providers for the United States. The reason that was primarily referenced for this coming shortage was a lack of adequate forecasting for an aging baby boomer population as stated here in a 2005 USA Today article:

The country needs to train 3,000 to 10,000 more physicians a year — up from the current 25,000 — to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon.

Certainly, there is truth to this idea. I personally get numerous job offers on a weekly, and sometimes daily, basis. But there is something that these studies and articles are missing. A number of doctors are also getting so fed up with medicine that they are choosing non-clinical careers; careers where they don’t do patient care.  This includes working for drug research companies, writing/editing, educating and even leavingmedicine altogether. I read an interesting article on-line by Dr. Kent Bottles in a Physician’s News Digest from 1999 that discussed some of the discontent doctors are feeling these days:

There’s a 1998 survey by Levin of 6000 physicians in 22 different cities that revealed that 46% of all American clinicians often think about leaving clinical practice. That’s over 300,000 physicians in the United States that seem to be unhappy with the state of affairs. There are other indications about physician discontent that you might not think of readily. The number of disability claims by physicians has increased so much that some insurance companies no longer are writing disability insurance for physicians. Recently the AMA, one of the more conservative organizations of physicians, has voted to form a union. And another example I saw was an article that said that physicians are actually moonlighting by selling cleaning products and herbs out of their homes. So, for a lot of statistical reasons and for a lot of those more soft reasons, it looks like physician discontent is widespread and happens throughout the whole country.

I am also personally one of the aforementioned doctors who has thought of doing something else with my life. Medicine has changed so much that it has become unrecognizable to some of the older docs, and it can sometimes be down-right depressing for younger ones like me. Sure, all jobs have the good and the bad right? But to me it seems somewhat different when you dedicate 10 years of your life to learn a skill and then have someone accuse you of intentionally and knowingly trying to harm them.

I posted an article yesterday about how we, as medical practitioners, had misled people regarding the “threat” of Strep throat. I stated that, statistically speaking, the risk of serious side effects from antibiotic use for this condition outweighed the benefit. And in turn, I received comments that reflect what we all unfortunately hear in medicine from time to time. That we “don’t care”, or that we diabolically “want people to suffer”.

To me, this arrow stings the most. That someone would really think that because I make a certain medical decision, that this means that I intentionally wish to harm them or cause them to suffer needlessly. Maybe I’m too young and haven’t yet developed skin thick enough to deflect these barbs. And then again, maybe I never want to develop such thick skin. If I did, then I wouldn’t be able to muster the compassion for other people who do trust us and don’t want to just give us orders.

Overall, I think it is a global phenomenon of lack of manners that has developed. As a doctor, I am humble enough to say that I will not be right all the time, and I don’t have to be. What I am charged with doing though, is not harming my patient. If you are a patient and reading this, please remember one thing. You can always get a second opinion. You don’t have trash someone just because the one snippet you heard on Oprah or read in Time magazine seems to contradict your doctor’s decision or advice.

Add to Technorati Favorites


You Don’t Need to Come to the ER at 3am for “Strep Throat”

May 15, 2009

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

Add to Technorati Favorites

Antibiotics for Strep Do More Harm Than Good
By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)

Add to Technorati Favorites