The practice of medicine is an emotional teeter-totter

Simulation games are a big part of the Telluride Patient Safety Summer Camp.  They are emotionally engaging, often high pressure situations, that mimic what can occur in clinical settings.  The lessons in teamwork and communication are embedded and lasting.  One such game is a teeter-totter--a plank on a cinder block--on which 7 people have to step up, one at a time, and hold the plank in balance--with the risk of getting off balance and "killing" an egg placed under each end of the board. (See here for a full description and explanatory pictures from a previous year.)

Here are some expressions of the residents participating in the game this week.

The residents arrive at Telluride

The second week of the Telluride Patient Safety Summer Camp has begun, this time with residents from around the country.  The opening ice-breaker consisted of people introducing each other to the assembled group.  Here's a selection of the assigned pairings.

Thanks to the Telluride faculty

And a short tribute to a few of the Telluride Patient Safety Summer Camp faculty members:

Anne Gunderson

Carole Hemmelgarn

Tracy Granzyk

Final views of Telluride students

Here are some images from the last exercise during the Telluride Patient Safety Camp, organized by facullty member Carole Hemmelgarn.

Negotiating at Telluride

The main focus of the Telluride Patient Safety Camp is to enhance the ability of doctors and nurses to bring about lasting change in the health care system to create safer and higher quality care.  A large portion of the curriculum is centered on the issue of improved communications in clinical settings.  Several years ago, organizer Dave Mayer asked me to present a module on negotiation, and I have done so at each session since then.

Obviously, in the short time allocated, I can't offer a full course on the theory and practice of negotiation, but we are able to cover some key topics and give the students a chance to practice them.  Here are some of the comments they posted later about the experience:

Our second session focused on negotiation skills and applying negotiation to clinical practice. This exercise was so fun! It required problem solving, critical thinking, planning, reflection, teamwork and open-mindedness to reach the best possible outcome of the deal. These are the same skills required by all members of the healthcare team to achieve good patient outcomes. Patient Safety is about harnessing the creativity of the human members of the healthcare team to come up with solutions for the patients in their care. (Alexandra)

Throughout medical school, I have enjoyed and actively participated in counseling patients about lifestyle changes, medication compliance, preventative care and other difficult issues. By implementing strategies of assessing readiness for change and instituting small changes, I had done a fairly good job in engaging patients to instill positive changes in their lives. Today,  I realized was that what I had been doing was negotiating with my patients. Negotiations are not easy, and I certainly fall short when negotiations involve finances, as I am less skilled in navigating this world than I am in the medical field. But I realized that these are vital skills that can be translated clinically.

Paul Levy taught us today that we need to get past the positions and think about the underlying interests. This presents an interesting and effectual way for us to negotiate with our patients and to create value for them. We must always remember that every patient has a unique motivation and the only way to uncover these motivations and use them for the benefit of the patient is to get to know them as individuals and not just as “patients.” I have a long way to go with my skills as an effective negotiator, but I am grateful to have realized what an important skill this truly is and will continue to practice until I get it right. (Ani)

Clarifying and understanding what was behind respective positions, trying to resolve both sides of the coin simultaneously where our and their interests became interlocked, we were able to work in a much more positive environment where differences did not drive us apart but rather served as a key source of value in negotiation. (Daewoong)

Faces of the Telluride experience (cont.)

Here are some more student faces and voices from this week's Patient Safety Summer Camp in Telluride, Colorado.

• Why am I here? I want to become a positive deviant, but I don’t know how. Over the years in med school I have learned tools and stories, but I have not seen the vision of sustainable positive cultural change that puts all these great things in one place.
• What do I want to take with me? Feeling rejuvenated, empowered to start a change. I do not want just another toolbox, but I want to catch the vision. A note from Daewoong.

Thinking back on our discussions today, the role of communication is crucial for safety in health care. One aspect that I think cannot be stressed enough is that communication is not just speaking well but also listening well. Health providers are often so preoccupied with the things they have to relay to others that they forget to truly hear others.  

The power of silence and active listening is sometimes more important and informative than any book, diagnostic test, or preconceived notions.  A note from Heather.

As I experience the absolute beauty of Telluride, CO I am so incredibly thankful to be in a new, exciting place for 4 days with beautiful scenery and equally beautiful people. The townspeople I have met on gondola rides or in shops have significantly enhanced the beauty of the place in which they live. Their welcoming spirits and adventurous selves have significantly added to my experience “out west” in Telluride, in the short day and a half of being here.

Similarly, my fellow Telluride Experience learners and faculty members have impressed me with their incredible stories, experiences and obvious passion for patient safety and quality improvement.  As I sit down to reflect on day 1 of the most thought provoking Summer Camp I have ever attended in my 22 years of life, I sift through my 7 pages of hand scribbled notes and can’t help but take a step back & wonder: how exactly did I get here? What made me apply? Where did this passion originate? What is it that I am so passionate about that made an eight hour day in a quaint school room seem like merely three hours? What is it that kept me so awake and so attentive throughout the day (aside from the two cups of coffee)? A note from Kathleen.

I never ventured out of the Florida and Georgia area, so getting a chance to see Colorado has been an amazing and inspiring experience. There are few things I enjoy more than driving so I decided to take on the 7 hour trek to Telluride after flying into Denver from Tampa, Florida. It was easily one of the most memorable experiences in my life. The natural beauty that I witnessed in Colorado and Telluride left me breathless and nearly in tears. I never imagined that something can be so perfectly created. Coincidentally I am at this summer camp discussing patient safety, where learning how to perfect our healthcare system comes naturally. Thanks to a wonderful faculty and the serenity of Telluride I had the fortune of seeing some incredible minds being inspired today. It is truly amazing to see so many of my future colleagues care so much about their patients. It is an absolute honor to be here. A note from Rahul.

“How could you let this happen?!” The thought raced through my head as doctors and nurses examined an ever-worsening Lewis Blackman in the series of events that led to his death.  As the information was presented in the video, it was exceedingly clear that the prognosis was getting worse and worse.  And yet everyone who cared for Lewis appeared to only see the snapshot of their interaction, decide that he was within normal post-operative ranges, and manage the symptom in isolation.

Prior to medical school, I worked and conducted research an engineer in wind and water resources. Data might be collected for multiple years before decisions were made to move ahead with a project.

Working with a patient, the appropriate course of action is not always clear and major decisions must be made as the data is acquired.  But from an engineering background, while it’s a challenging problem, it’s a problem that can be solved.  We need to ensure that all the information – collected by the physician, by the nurses, and reported by the patient and family – is communicated and clearly available.  We need to ensure that decisions aren’t swayed by fatigue, by time limits, by organizational demands, or by peer pressure.  And we need to engage the team in solving the problem, because ultimately, this should not be another onerous top-down requirement, but an exciting opportunity to do better. A note from Shara.

After hopping on the gondola and experiencing one of the best morning commutes I could imagine, we settled in for a day filled with thoughtful discussion, heart wrenching stories and collaborative learning. Unlike many of my colleagues here, I have a very limited background in quality improvement and patient safety. I am here because of a personal experience where a family member of mine was subject to a medical error that rocked our family and forever changed it. I came to seek out knowledge that I feel is one of the most important topics I should be learning in my medical school curriculum but has been largely absent, at least so far. I also just completed my first year of medical school so I also have a very limited exposure to working in the hospital and seeing these errors occur from the physician and nurse’s side. For this reason I am so grateful to be put together with this group of people who are able to contribute so many different perspectives and experiences that I can feed off of and discuss these difficult topics with. 

I learned so much in one day at Telluride and I cannot wait to see what the next few days bring. Being a part of this experience so early in my education is empowering. I feel very lucky that there is such an incredible group of people passionate enough about patient safety to bring all of us out here and share with us lessons and tools that will help us be better health care providers and begin changing the culture in which we care for our fellow human beings. A note from Valerie.

Faces of the Telluride experience

Here's a small compendium of some faces (students and faculty) from this week's Patient Safety Summer Camp in Telluride, Colorado.

As a freshly minted physician, I understand the routine of patient care. I have seen rushed explanations of informed consent and abbreviated histories and physicals; I even admit to doing it myself in the name of efficiency. But I want to grow, I am willing to listen, and I am ready to be inspired. As I prepare for my internship and residency in anesthesiology, I realize that the status quo of the current medical culture is inadequate, and that my exposure to formal and informal learnings and discussions on patient safety and quality has been limited. I am hopeful that this roundtable will help me become a more compassionate anesthesiologist, a more skilled instructor, and a more thoughtful team member.  A note from Dora.

All too often, patients are harmed in hospitals at the hands of well-intentioned providers. More often than not, when an event like this happens, a member of the care team had an inclination that something was wrong or unsettling but did not feel like they had the authority to speak up on the patient’s behalf. As a medical student, I have felt at times as though my job is to observe and absorb without offering input. The story of Lewis Blackman reminded me of how dangerous this attitude can be– silence and reticence to “bother” an authority figure ended up costing an innocent young man his life.

To keep things in perspective as I progress in my career, I’ll re-frame Dr. McDonald’s advice as it applies to team dynamics in the clinical setting: if I see something that concerns me, what’s the worst thing that could happen? If I raise the issue with a superior, could they find me incompetent or annoying? Maybe. If I don’t raise the issue, could another human being pay the ultimate price because I was more concerned with self-preservation than the safety of my patient? Maybe.

Through this lens, the choice is easy. No one ever died from looking stupid. A note from Elizabeth.

Each “tribe” has their own biases about the other “tribes” in the hospital including the patient and their family....

I am fortunate coming from Seattle and working at Virginia Mason to have been exposed to these ideas long ago, and they have driven me to where I am today. However in my current education, I am learning in a silo and have no clue what medical students, nursing students, pharmacy student and so on go through in their education and training. Being here today I had the realization that we must all work together as a team to accomplish an environment that supports patient safety. While each tribe has biases of the other, we must work together to break down barriers to better understand each other’s work. We have the luxury here at Telluride of already having a mutual purpose established. Going forward in my career, I understand the importance in establishing that mutual purpose with my stakeholders and engaging the staff. Sometime that means finding a champion to help get the message out. My role is going to be establishing that mutual purpose for all the tribes to create one unified tribe of healthcare workers that with speak up for patient safety. A note from Evan.

As healthcare providers, we need to remember that our goal is to provide our patient with the best care possible and do our best to ensure a positive outcome. While there are many tasks involved in this, we need to remember that our patients are more than just a diagnosis or a set of vitals. They are real people with real fears, concerns, and questions. Giving the best possible care means respecting the patient enough to take the time to address these issues with them and include them in their care. I feel that working together as a team in this way will help increase patient satisfaction and also improve patient outcomes. A note from Kathleen.

Before I started medical school, I spent a year working at a free clinic in Moab, UT. If you aren’t familiar, Moab is a small town of about 5,000 people sandwiched between Canyonlands and Arches National Parks–some of the most stunning landscape in the world. At the Clinic, we serve the many people who work to keep this popular tourist town (it has over 2 million visitors per year) running. As a first year medical student, I don’t have a ton of experience working on the hospital floors, but in Moab I worked as part of a two person staff where I coordinated our clinical volunteers and was the main point of contact for most of our patients’ follow-up care.

At the time, we were a clinic run entirely by non-medical personnel, so we rarely used the vocabulary of quality improvement and patient safety that I’ve since learned in medical school and in the first few sessions of the Telluride Summer Camp. However, I’ve come to realize that we prioritized patients’ needs, primarily through open communication between volunteer providers, clinic staff, and patients about the plan of care. We didn’t necessarily have protocols–we all sat as a team and discussed each case and each team members’ responsibilities. Much of this was done on the fly, but we seemed to have a pretty good system for making sure folks didn’t fall through the cracks. A note from Sean.

Who cares for the public trust?

The story of Lewis Blackman's untimely and unnecessary death always leaves an empty feeling in the hearts of our Telluride Patient Safety Camp participants--especially when they read his mother's summation above.  It also leaves them with tremendous admiration for Helen Haskell, who has used this terrible experience to help the next generation of doctors and nurses reduce preventable harm in hospitals.

The case is bad enough in itself, but how much more of an insult to the family was the publication of an article in a medical journal.  As I have noted:

Less than a year later, an article was published in the Journal of Pediatric Surgery (J Pediatr Surg. 2001 Aug;36(8):1266-8.), authored by Lewis' surgeon and others.  The authors described the application of the minimally invasive surgical technique used for Lewis.  They pointed out that in 20 cases studied:

"Average length of stay was 5.5 days. There were no early complications. Mean follow-up was 12 months. . . . One patient had a prolonged hospital stay of 7 days because of postoperative pain."

How could these study results be correct when Lewis had died the previous November, just a few days after the surgery?

We have to assume that the sampling of patients used by the authors ended in a manner that excluded Lewis' case.  

Helen brought this issue to the attention of the editor of the JPS:

You may imagine my surprise when I read the opening sentence in the results section of this article, "There were no deaths either after the MIRPE or the MRR." Lewis was a healthy child who died as a result of complications of the pain management regimen for the MIRPE procedure. Pain management has been a major problem for this procedure. While there were certainly standard of care issues involved in his death, that surely can be the case with any surgical complication, in any institution. This outcome can by no stretch of the imagination be considered irrelevant to a discussion of complications of this surgery.

The retrospective chart review in this study was structured so as to terminate four weeks before Lewis' surgery. While this may technically provide a rationale for failing to mention what can hardly be considered an inconsequential complication, it cannot help but raise questions about the intention of the authors, three of whom were intimately aware of Lewis' case. 

The response was vacuous, with:

the editor saying the article had been "peer reviewed by three editorial consultants." He acknowledged that "the patients in the study . . . preceded the date of your son's experience," but "based on the information you have provided, the content of [the] manuscript would not be altered."

I mention this aspect of the Blackman case again because I have seen too many similar examples--  cases in which an ambitious surgeon with a new technique or using new equipment takes on a case without providing full disclosure to the patient or family about the potential for increased risk compared to proven methods.  Some hospitals are complicit in promoting such "experiments" by not requiring IRB approval (i.e., human subjects review) or approval by some peer ethics committee.  They (surgeon and hospital) do this for business reasons, to offer themselves in a competitive marketplace as having "the latest and the best."  The surgeon then writes an article proclaiming the success of the new procedure, but that article seldom or ever looks at the long-term consequences, and it never indicates why--in terms of risk to the patient--the new procedure went forth in the first place.

Even in an era of increased patient advocacy, we can't expect the Helen Haskell's of the world to take on surgical or other specialist societies and their associated journals.  Absent action by the doctors or hospitals themselves to apply appropriate standards, it lies with regulatory agencies or the press to publicize these ethical lapses.  To date, in my judgment, both groups have often failed in their protection of the public trust.

Students arrive for the Telluride Experience

It's June in Colorado and so time again for the Tellluride Patient Safety Camp experience, now known as The Academy for Emerging Leaders in Patient Safety: The Telluride Experience.  We start this week with medical students and nursing students.  Next week the residents return.

Dora and Kevin

Before the formal sessions start tomorrow, we began with an ice-breaker in which students are paired with a colleague and then have to provide a synopsis of their partner's life for the rest of the crowd. Chicago's Kathy Pischke-Winn, (below left) served as MC as patient advocate Dan Ford looked on. Good humor prevailed.

The player teaches the coach

Please take a look at this article over at the athenahealth Leadership Forum, which I offer with thanks to one of my soccer players for reminding me of an important lesson.

Soccer Haiku

By Kris Mukai in The New Yorker

For the soccer moms and dads out there.  Some delightful poems published in The New Yorker, and written by Sam Cohen, at the University of Missouri.  They are inspired by conversations he overheard at his children’s soccer games and practices.

Indoor Field, January 31, 2015, or, Song of the Parents

SHOOT IT, OWEN, SHOOT IT
GO GO GO
QUIT PLAYING WITH YOUR SOCKS, ZACH
THAT’S YOURS THAT’S YOURS
UH OH
GET TO THE MIDDLE, SOPHIA
PAY ATTENTION
GIT IT GIT IT GIT IT
OH

Field 3, March 18, 2015, or, The Mouths of Babes

Aidan
Aidan
I’m open
I’m wide open
Hey

You can’t shoot it every time
You’re like a mile from the goal
I’m all by myself in the middle there

At least give and go
Wall pass
Triangle pass
Pass to me
I’ll pass it back
I swear

Field 12, March 18, 2015, or, The Mouths of Babes II 

Whose man was that
I can’t cover everybody
I’m just one kid

Practice Field, April 16, 2015, or, Pelé’s Sister

You call that a settle
Settle the ball, Blake
Right in front of you

We don’t kick like that, Blake
Blake, we don’t kick with our toes, do we
Blake, no toe bombs

Nice cross, Grace
Gracie, way to hustle
Blake, watch Grace

Do you understand drug pricing?

Prescription version and OTC version

Notwithstanding several years in the health care field, I still have trouble understanding retail drug prescribing and pricing.  Here's the latest example.

I use Nasacort (a nasal corticosteroid, triamcinolone acetonide) for hay fever symptoms, and it works very well. Each year, I send in a prescription request to my PCP, and then I go to Walgreen's or CVS to pick it up. This year, the price was well over $100, since my insurance plan no longer covered it. When I expressed surpise, the phramacist said, "Why don't you buy the OTC version?  It's much less, and it's the same thing."

Sure enough, a comparable quantity was about 25% the cost of the prescription version.

I now have learned that the OTC version was authorized by the FDA on October 11, 2013.

My questions are basic. Why does my primary care practice still issue prescriptions for this medication instead of just sending people to the OTC version?  Why does a prescription version still exist, and why is priced so far above the OTC version?

Money coming in through the back door?

Robert Pear at the New York Times offers an excellent summary of findings by the General Accountability Office that the procedure used by the Medicare agency (CMS) to determine the relative weightings for $70 billion physician payments has major flaws.  That CMS weighting is also used by most private insurance companies as the basis for physician payments.  This is a topic that has received coverage over the years, but little has changed.

(A pause here to ask and refer back to a previous post:  When was the last time you heard one of the Triple Aim advocates—inside or outside of CMS--take on this issue, which has a direct result in how much primary care doctors and other cognitive specialists get paid?)

But, there is an important reminder in this story.  Pear notes (with my emphasis added):

“Under federal law, Medicare fees are supposed to reflect the time required to perform a service and the intensity of the work.”

Uh oh.  Let’s consider how the pervasive use of robotic surgery will factor into this calculation.  For example, in the past, most prostatectomies would have been done as open procedures or using a manual laparoscopic approach.

Now, due to a highly successful marketing campaign by Intuitive Surgical and by doctors and hospitals that have showcased their robotic surgery program, the vast majority of these cases are performed robotically.  This has increased the required time in the operating rooms.

The same applies to other procedures in which Intuitive has made and will make inroads—gall bladder removal, hysterectomies, hernia repairs, and so on.

Is this a back-door way for surgeons to receive more money for the same procedures?

This is too serious for monkeys

The folks of Portsmouth Hospitals NHS Trust have drafted a rather odd looking monkey, Rocky, as their mascot in support of a fund-raising campaign:

The appeal is now aiming to raise £2.4 MILLION for a Da Vinci Robot, which will take surgery to a whole new level here at QA Hospital. There are only 14 Da Vinci Robots currently in the UK. This technology is not available at Southampton or Chichester, our nearest neighbouring hospitals.

Echoing the language from the manufacturer, Intuitive Surgical, they say:

The surgeon will sit in a console controlling the robot, in a 3D environment, at the patient’s side. This will enable more precise surgical techniques to be used, especially in small areas of the body such as the pelvis, head, neck and throat. Many hundreds of patients from Portsmouth and surrounding areas, the Isle of Wight and Jersey will reap the benefits. Patients being admitted for cancer problems such as prostate, gynaecological, colorectal, kidney, bladder and head and neck, will benefit from having no major open surgery thus allowing for a much faster recovery time and return to home and working life.

And even in a single payer system, the emphasis is on a competitive advantage:

We intend to make Portsmouth a leading international centre for Robotic Keyhole Surgery, and attract the best talents here to benefit our patients. We hope that you will share our vision, and if there is any way that you are able to help us, we will be forever grateful. Once we achieve our goal we will be one of a few hospitals in the country to offer these services, making Queen Alexandra Hospital one of the finest.

They seem to forget about the cost of disposables and the annual maintenance contract:

Thanks to all of our supporters, so far we have managed to reach our first milestone of £500,000 leaving another £1,900,000 to raise to reach our £2.4 MILLION target. To enable us to be in the forefront of Robotic Surgery we decided to have the robot now – however we still need to make regular payments so that we can keep it. To lose it would be a major blow to all patients now and in the future.

A lot of monkey business, if you ask me. These machines are expensive, and their supposed benefits are overstated and unsupported by objective clinical studies.  Your money could be much better spent elsewhere.

A walk from the country

I received this note:

Join the rally cry for rural hospitals.

Walk with us to Washington, DC to save rural hospitals in America.

Rural hospitals are facing the greatest challenge to their existence in the history of our country. In the next year, 283 rural hospitals face the uncertainty of possible closure. It is time to act. We are asking rural hospitals from all over the country to send a representative to our June 1st, 2015 walk from Belhaven, North Carolina to Washington DC to petition Congress to pass measures to ensure rural hospitals sustainability. 

I was curious, as rural hospitals already get special treatment from the Congress.  For example, this article in Modern Healthcare notes:

A law that allows rural hospitals to bill Medicare for rehabilitation services for seniors at higher rates than nursing homes and other facilities has led to billions of dollars in extra government spending, federal investigators say.

Most patients could have been moved to a skilled-nursing facility within 35 miles of the hospital at about one-fourth the cost, HHS' inspector general said in a report being released Monday. Hospitals juggling tough balance sheets have come to view such "swing-bed" patients as lucrative, fueling a steady rise in the number of people getting such care and costing Medicare an additional $4.1 billion over six years, the report said.

The authors wrote that the windfall helps to "support a hospital's fixed costs and offset losses from other lines of business."

Legislation passed by Congress in 1997 created the designation of "critical access hospitals" to help small facilities in remote areas survive. Rather than paying set rates for services as throughout the rest of the Medicare system, the federal government reimburses the hospitals for 101 percent of their costs. They also often receive state funding and grants.

So I went to the walk website to see what more I might learn. It said:

Rural hospitals are facing the greatest challenge to their existence in the history of our country. In the next year, 283 rural hospitals face the uncertainty of possible closure. It is time to act. 

Now it is time for America to stand up and demand that Washington DC work on our rural hospital crisis. Our rural hospitals are just as important as any urban medical centers. We feed America and deserve to keep our current level of healthcare. When hospitals close, emergency rooms close and that means needless deaths -- our children, family members and neighbors. We have to stand up for ourselves and THE WALK will get Washington’s and the nation's attention.

Not helpful, so I looked elsewhere. It may be that Medicare's zeal to reduce readmissions and apply penalties to the "laggards" has an impact:

The Affordable Care Act was designed to improve access to health care for all Americans and will give them another chance at getting health insurance during open enrollment starting this Saturday. But critics say the ACA is also accelerating the demise of rural outposts that cater to many of society's most vulnerable. These hospitals treat some of the sickest and poorest patients — those least aware of how to stay healthy. Hospital officials contend that the law's penalties for having to re-admit patients soon after they're released are impossible to avoid and create a crushing burden.

But is also seems to be a state--not federal issue--arising especially in those states that have not chosen to use the terms of the Affordable Care Act to get federal aid to put more people on Medicaid:

Department of Health and Human Services Secretary Sylvia Burwell, in office since June, grew up in rural West Virginia and says she is "particularly acutely focused on" the challenges facing rural hospitals. More Medicaid expansion would go a long way toward addressing them, she said in a news briefing in October.

But the article offers mixed signals on that issue:

Low Medicare and Medicaid reimbursements hurt these hospitals more than others because it's how most of their patients are insured, if they are at all. Here in Stewart County, it's a problem that expanding Medicaid to all of the poorest patients -– which the ACA intended but 23 states including Georgia have not done, according to the federal government — would help, but wouldn't solve.

I'm not sure why the article refers to low Medicare reimbursements, given the special treatment of rural hospitals.  The Medicaid rates, again, are a state determination.

This summary seems to get to the heart of things:

Half of the rural hospitals that shuttered since early 2010 closed completely. Many of the rest now operate as rehabilitation and nursing facilities, or outpatient clinics. A few operate as emergency departments or 24-hour urgent care centers, offering some — but far from all — the services the former hospitals did. But Lewis and others say that while these 24-hour facilities could stabilize stroke or heart attack victims before they head on to larger hospitals, they are even less financially viable, given the poor, uninsured populations they serve and the fact that emergency rooms are the most expensive parts of hospitals.

Here's my take, but I'm happy to be corrected.  Rural hospitals have received special protection from the US government for years, as each Congressional district has them and as they are often the major employers in small towns. The degree to which they've operated as more full service institutions was only sustainable because of federal support, and many have likely incurred investment and staffing costs to offer services at a level that could not be justified, in terms of clinical volumes. Now, the pendulum has swung a bit, and a number of these hospitals are finding that the current revenue mix is unfavorable. With nowhere else to turn, the politically active local officials and advocates are going back to the well for more federal assistance.

And so it is here that we turn to Congress which, because of self-imposed limitations on the federal budget, will find itself making choices between these local hospitals and--among other things--funding for graduate medical education in the urban academic medical centers.  We are about to see zero sum politics in action.  Rural versus urban.  Community hospitals versus AMCs. Meanwhile CMS quietly supports incredibly wasteful investment in other areas, in response to behind-the-scenes lobbying from equipment manufacturers and investment bankers. I don't think this will be pretty.