The Clare Spark Blog

March 18, 2017

Dr. James Pagano on the reasons for a doctor shortage

Filed under: Uncategorized — clarelspark @ 2:49 pm
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The doctor shortage is real and most acute in certain specialties, like family medicine, internal medicine, and pediatrics.  There are various reasons for this.  Economics of course-these specialties pay less that others.  But over the course of the past 7 years under the ACA the bureaucratic and regulatory burden that has been placed on office-based primary care doctors has become so onerous that many are retiring early and fewer students are willing to enter those areas of medicine.

To counter this graduate schools are cranking out ever-increasing numbers of ‘mid-level providers’—physicians’ assistants and nurse practitioners.  As I’ve mentioned previously, these providers can do an excellent job in certain situations, but they don’t have the breadth and scope of knowledge a physician has.  Another trend of Obama era medicine was the development of ‘best practices’, ‘core measures’, and various diagnostic and therapeutic algorithms.  The alleged purpose was to identify the most appropriate approach to various illnesses and presenting complaints and to create a checkbox system of treatment.  Financial penalties were instituted against providers and hospitals for non-compliance.

My own suspicion was that CMS wanted to create a centralized system for delivering health care that did not rely upon physicians to administer it.  A mid-level could use the guidelines and get it right for something like 85% of the people 85% of the time.  Population medicine was the focus of the physicians and politicians working for the Obama CMS—and much of the paperwork being required of office-based doctors is providing data on treatments and outcomes to generate more algorithms.  Not all of this is bad.  Some useful information will be gleaned and some more effective or efficient or affordable treatments will be developed.  It is not, though, the type of practice doctors of my generation were taught.  We were taught to study the evidence and then use our clinical skills to tailor our therapies and diagnostic evaluations for the benefit of individual patients.

An example of check box medicine run amok is the core measure for the treatment of sepsis.  Briefly, sepsis is a condition of systemic infection with abnormal vital signs and evidence of failure in one or more organ systems.  It has a high mortality rate, especially if not diagnosed early and treated aggressively.  As part of the core measure for sepsis, patients have to have lactic acid levels drawn and repeated.  This value is used to determine whether or not sepsis is present, and if so, to what degree.  Unfortunately many other conditions besides sepsis can cause an elevated lactic acid level.

For ‘severe sepsis’, defined by the CMS as a lactic acid level greater than 4, the patient is supposed to be given a 30 cc per kg bolus of saline IV.  Regardless of whether or not the patient has another underlying condition, like renal failure or congestive heart failure, that would make this fluid bolus dangerous and possibly fatal.  If the fluid isn’t given the case falls out of compliance, the doctor and hospital don’t get paid, and this ‘poor performance’ is published on line by the CMS for all to see and few to understand.  Even if the physician documents clearly why the fluid is being withheld or the amount modified the case is still considered a fall-out.  This absurdity was recently reviewed by the CMS and kept in the protocol.

This sort of governmental interference leads to cynicism among physicians, nurses, and hospital administrators.  It would be more honest for the CMS to simply say they don’t want to pay for certain care than to create a bogus protocol that needs to be gamed in order to be compensated.  A study was done and published in the New England Journal of Medicine a year or so ago in which the authors compared the outcomes of patients with sepsis treated either according to protocol or according to clinic judgment.  The study found no significant improvement in outcomes among those patients subjected to the protocol.  The Obama ‘science administration’ did much to pervert science across its broad spectrum, from the environment to healthcare.  Maybe some of this gets fixed over the next few years.



October 16, 2014

Ebola, the CDC, and Government Ineptitude

Filed under: Uncategorized — clarelspark @ 12:59 am
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James Pagano, MD

James Pagano, MD

This is a guest blog by James Pagano, M.D., and author of two novels

Dr. Tom Frieden, head of the CDC, appeared in a taped interview last evening on Megyn Kelly’s program. His intention was to answer some of the questions regarding his handling of the Ebola problem, to explain why the things he is or isn’t doing are correct, and to reassure the audience that all would be well.  He failed miserably.

The CDC and Dr. Frieden are likening Ebola to hepatitis or HIV. Like Ebola, both are diseases caused by viruses, and both require contact with infected body fluids for transmission from one individual to another.  Neither, though, is anywhere near as infectious.  In the case of HIV, a healthcare worker who experiences a needle stick injury from a needle contaminated with an HIV patient’s blood has about a 0.3% chance of being infected.  By comparison, it appears Ebola can be transmitted by coming into contact with minute amounts of fluid, such as that which could be on the exterior surface of a protective gown.

Pagano's first novel

Pagano’s first novel

A disease that infectious, with a mortality rate of over 70% in Africa and at least 50% if contracted and treated here should be taken seriously. Everything that can be done to prevent its spread in this country should be done.  Unfortunately that is not how it is being handled.

The only effective way to stop an outbreak of a lethal illness for which there is no specific treatment is by isolating those who already have the disease and preventing its spread to other areas of the globe. This requires travel restrictions and quarantine.  While we are still able to identify West Africa as the danger zone such restrictions would be relatively easy to impose.  Anyone wanting to come to this country from West Africa and anyone who has been in that area would need to wait 21 days before being allowed to come.  It would require checking passports and keeping people with stamps from countries in which the disease is epidemic off planes until they are cleared.

Dr. Frieden disagrees. He believes that such restrictions would somehow make the outbreak harder to fight in Africa and put us in greater risk here.  He cites difficulty getting healthcare workers and others joining the fight into and out of the area as one of his major concerns.  This is absurd.  His logic is so convoluted it causes one to question everything else he has to say.  It is possible he’s parroting the party line.  If so, he should admit it, say what he really believes, and offer to step down if it displeases his boss.  The stakes here are far too high for political correctness, or politics at all.

He then goes on to say much is known about Ebola, how it is transmitted, how it can be stopped. Given his rationale for not limiting travel one wonders.  It is true that Ebola requires contact with infected body fluid to pass from one person to the next.  In that way it is similar to HIV and hepatitis.  How much body fluid is required is unknown.  During the height of the AIDS epidemic I ran an emergency department in a hospital with an HIV ward.  The disease at that time was a death sentence for those who contracted it.  Still, it was our understanding that it could not be transmitted by casual contact.  The only time we put on gloves, gown and mask was if we were drawing blood or performing some invasive procedure.  Very few healthcare workers were infected by patients, and those who were had exposures to large amounts of infected material or had been accidentally stuck with a hollow needle previously in the vein of the patient.

By contrast healthcare workers treating Ebola patients are dying by the hundreds despite wearing haz-mat suits.  This is a different disease.  There are even studies in animals that suggest certain types of Ebola can be transmitted through the lungs.  People from endemic areas should stay put until they’ve been quarantined for the full length of the incubation period, 21 days.

Another of the CDC’s proclamations is that any hospital with an isolation room can safely handle an Ebola patient. This is also nonsense.  Meticulous care must be taken with barrier protection to maximize safety.  It is nearly impossible to remove the booties, gowns, mask, goggles and gloves without at some point touching the exposed surfaces with either your bare hands or your clothing.  It requires a lot of practice.  Community hospitals that may see one potential case will not have sufficient experience to treat the patient safely.  And this doesn’t address the risk to other hospital personnel, such as phlebotomists, lab techs, and housekeeping.

Saying the CDC will offer training to thousands of doctors and nurses is not only absurd, but pointless. To receive the best care, these patients should be treated in designated centers by dedicated teams of physicians, nurses, and ancillary staff.  The role of community hospitals should be that of recognition, isolation, notification of health officials, and transfer to a designated center.  This can be done by the ER staff.  Instead of trying to train everyone in every hospital, training the ER staff is something that is actually feasible.

Emergency departments across the country are experiencing increased patient volumes due in large part to the ACA. The one at which I am the medical director is busier by more than 20% year over year.  We are on the verge of the winter flu season which typically brings an addition flood of patients to the ER.  This is a bad time to add Ebola to the mix.  Travel restrictions to minimize the chance of an infected person entering the country would go far to protect both the healthcare workforce and other citizens from this disease.  Coordinated care at specialized centers will give those infected the best chance of survival while at the same time minimizing the spread of Ebola.

It makes no sense to assume everything will be all right until we’ve done everything possible to ensure the best results. So far the CDC, and its leader, have not convinced me they have done so.

[Update 10-17-14, from private communication to Clare Spark: “Whether we have a large outbreak in this country or a small one, the disruption of the healthcare delivery system will be devastating. For the past two weeks we have been running drills on how to safely don and remove the various pieces of barrier protection we’ve been advised to wear when dealing with a potential Ebola patient. These drills have been almost slapstick. The gowns, etc., are inadequate and it is practically impossible to remove everything after the patient encounter without contaminating yourself. I am certain hospitals across the country are experiencing the same difficulties. The early Obama claim that ‘any hospital with isolation capability can care for an Ebola patient effectively and safely’ belies a complete failure to understand what we are facing. Interesting that the most recent cases have been transferred to designated treatment centers.

We are about to enter flu season. Thousands of people with fever, vomiting, diarrhea, and headache will be presenting to ER’s. These are the same symptoms someone in the early stages of Ebola will exhibit. If we have 20-30 confirmed cases around the country and no travel restrictions ER personnel will be forced to approach every patient with these symptoms as a possible Ebola patient. A crowded ER, and ER waiting room, are not ideal places for a number of these patients to be boarded. The amount of time the ER staff will need to care for them will increase exponentially because of the isolation and gowning precautions. The system will experience huge delays, patients will be placed in danger, and the ER staff will be overwhelmed.” [End Pagano update.] Dr. Pagano also points out that nine physicians have died in Africa treating Ebola. No time to be sanguine about Democrat management of this crisis.

Frieden as educator

Frieden as educator

October 10, 2012

Obamacare–One Last Time (James Pagano, MD)

Filed under: Uncategorized — clarelspark @ 6:00 pm
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James Pagano, M.D.

[For previous blogs by Dr. Pagano, see This has link to the first blog.]

As the election draws close and the race tightens it seems a good time to take one more look at what is about to befall us as patients and consumers of healthcare.  In the past I’ve spoken from my perspective as a career Emergency Medicine specialist, a physician for over thirty years, practicing at the precise point where the worlds of medicine, politics, and public policy collide.  I have been, and continue to be, a part of the safety net everyone pays lip service to but few truly understand.  I have had a lot to say about why I think Obamacare, (an acceptable appellation since the president himself adopted it during the recent debate), is a disaster.

But, having recently entered my seventh decade, I have new concerns.  Not as a provider of healthcare, but as a consumer.  A patient.  A soon-to-be- senior on Medicare.  Having spent the bulk of my productive life providing first-rate care to others, what is going to be available to me in the years ahead?  Well, that depends.

Both Governor Romney and President Obama agree that under the new healthcare law 716 billion dollars will be removed from the current Medicare budget.  Starting now.  Romney calls it a cut in Medicare spending.  Obama calls it a savings.  It is a ridiculous distinction if you believe that all money is saved the same way.  Whether it is from ones childhood allowance, the family household budget, or the government-sponsored portion of healthcare, money is saved by not spending it.  Despite all the bluster and obfuscation it really is that simple.  A penny saved is…well, you get it.

So let’s call it a savings.  Fine.  How, exactly, does Obama think this savings is going to be realized?  To understand that we must take a look at what gets paid for under Medicare.  Doctors, allied healthcare providers, hospitals, drug manufacturers, the retail outlets that sell the medications to Medicare beneficiaries, and device manufacturers—think about the titanium hip that could be in your future—are responsible for just about all of Medicare’s budget.  Note that there are no jewelry stores or exotic car dealerships on the list.  We won’t be saving a dime by not paying for frivolities.

What, then, will not be paid for to achieve these savings?  Obama cites overpayments to providers and hospitals as being a principal source of savings.  The problem with that is the fact that Medicare already pays less than most insurance plans now.  Under the current fee schedule many physicians, particularly surgical subspecialists—there’s that hip again—are not accepting new Medicare patients.  If the proposed fee cuts scheduled for this January are allowed to go into effect, Medicare will look a lot like Medicaid.  In that scenario you can expect more physicians to not only refuse to take new Medicare patients, but to possibly opt out of Medicare altogether.

Hospitals, too, will have to reconsider their participation in the program.  They are currently paid according to a DRG system—Diagnostic Related Groups.  Every diagnosis is given a dollar value and a maximum in-patient length of stay.  For the hospital to make money, it must not spend more on the care of a patient than it will be reimbursed.  If your DRG says you can stay for 2 ½ days and the total cost will be $4300, then to make money the hospital has to keep you for sometime shorter and spend something less.  Cutting the amount allowed will lead to fewer services being provided.

To date hospitals have managed to do well in the Medicare system, and many are looking to Obamacare to provide additional revenue by covering the uninsured, who currently pay nothing for their hospital care.  However, drastic cuts, I mean savings, in the Medicare program combined with a massive influx of underinsured Obamacare patients will, I think, change things.

One of the biggest sources of ‘savings’ will come from something no one currently supportive of the healthcare law wants to discuss—healthcare rationing.  Like the systems in Canada and Great Britain, certain services will not be made available to certain patients.  If you need a hip, but are overweight, you might not get it until you reduce, if at all.  If you have cancer, but it is going to cost more than, say $47,000 per year of ‘quality’ life to treat, you won’t be treated.

The decisions about what constitutes ‘quality of life’, what therapies will and will not be made available, who, basically will live a while longer and who will not, will be made by a 15-member board, the great majority of whom not medical professionals, appointed by the president and not answerable to congress or the people whose lives they will control—patients on Medicare.

Much of this may not have been clear to many when the law was enacted, and much was still unclear when the Supreme Court voted to uphold the law—while specifically stating they were not in the business of protecting the People from their own bad political decisions—but it should be clear now.  If you are currently on Medicare or will be soon, you are in trouble.

We have heard a lot from this administration about the Republicans’ ‘wars’ on a variety of things—the alleged ‘war on women’, the ‘war on the middle class’, the ‘war on immigrants’, and it has become tiresome.  Phony wars devised by this administration to hide from view the only real war being prosecuted—the war on Medicare recipients.  The war on seniors.  It is real, it is happening now, and Obamacare is its name.

Romney’s healthcare plan will change nothing for those of you on Medicare now, or the rest of us age 55 and older who expect to be on Medicare sometime in the next 10 years.  We who have worked, planned, and saved according to a social promise made years ago will be able to reap that benefit in full.

For those younger than 55 there will be money given to offset the cost of buying an insurance plan.  The amount provided will vary according to need, as it should.  The Romney system mirrors that currently available to members of congress and their families.  It allows for choice, puts patients and their doctors in control of their healthcare decisions, and keeps Medicare viable into the entire foreseeable future.

As always, there will be a safety net for those who fall through the cracks.  And, as always, there will be someone like me providing that care.

Obamacare was never about healthcare in the first place.  It was about wealth redistribution using government-controlled healthcare as the means.  If it was about improving healthcare, and if it was to be his signature piece of legislation, why was implementation delayed until after the re-election bid?  If it is so good, why not implement it before the election so it’s wonderfulness could be touted as a reason to re-elect?

Whether or not you share this administration’s desire to redistribute wealth, I am fairly certain you would like to maintain your current level of healthcare quality and access.  You would like to ‘keep your doctor’.  The only way that is going to happen now is by voting Obama out of office.

James V. Pagano, MD, FACEP

March 19, 2010

Dr. James Pagano on Obamacare

Filed under: 1 — clarelspark @ 11:01 pm
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Hygeia: Roman copy of Greek statue, in Hermitage Museum

[This is a guest blog by my friend, emergency room physician, Dr. James Pagano:]

“The longer this drags on the more obvious it becomes that the bill is a complete disaster and the process of getting it passed is bordering on criminal.  The cost estimates are completely trumped up, the deficit reduction Obama is touting is a fantasy.  The end result if this is passed and allowed to actually go into effect will be a severe erosion of health care in this country for everyone for the alleged benefit of the few–alleged because they will be given the equivalent of Medicaid, which is almost worthless, at the cost of degrading Medicare to a level of near-worthlessness, increased taxes on just about everyone who actually pays taxes, decreased access to physicians, limited choices of therapies, extreme rationing of services to the elderly and ‘non-productive’, and the eventual creation of a single-payor system run entirely by the government, with annual escalations in the cost that will cripple our ability to maintain any sort of leadership role in the world.

 But that’s the whole point, isn’t it?  Obama doesn’t care about our health.  He cares about creating the socialist utopia–the utopia that has never been realized in the past though it has been tried on numerous sad occasions.  He doesn’t want the U.S to play a leadership role, he wants us to succumb to a new world order.  He is so ridiculously naive and ideological it depresses me that so many seemingly intelligent people were fooled by his smooth rhetoric, and that many are still unable to see through his systematic, ‘do whatever it takes’, lies and deception.

 Many physicians understand that this will be the final, fatal blow to their careers.  The trial lawyers, (think John Edwards here), have succeeded in taking the joy out of the profession, and now the socialists will take away our ability to earn the sort of decent living we deserve doing the essential, stressful, time- and education-intensive work we do.

 Our hope lies in the up-coming elections.  To save health care, and our entire way of life, we must get the democrats out of office.  If we can do this, much of what Obama is trying to do can be undone.  There will be a spate of legal challenges to this bill the minute it passes–these, too, offer a measure of hope.  Finally, we have to make certain that this president does not last more than one term.”

[Clare: my father was a physician who always treated poor and lower-middle class patients. He was opposed to socialized medicine in any form. Non-physicians may have little idea of the stress and danger experienced by idealistic doctors.]

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