Monday, June 22, 2009

Seventy per cent

Coincidentally, this figure not only represents how I felt this morning but also, on the basis of a recent Dartmouth study, the amount of health care in the U.S. which is thought to be appropriate. It has been postulated that eliminating the 30% of inappropriate (unnecessary) care would pay for a comprehensive national health plan several times over. An article in the New Yorker describes the abuses occurring in McAllen, TX where nearly twice as much is spent per capita than in other regions of the country; notably, the patients in McAllen are no sicker and fare no better than their cohorts living elsewhere. This article is now required reading on Capitol Hill. But this is hardly news. I am reminded of the scene in Casablanca when Claude Rains says, "I am shocked, shocked that gambling is going on in here." In point of fact, I see it on a daily basis. I see patients undergoing annual stress tests without a clear indication. I see stents implanted in insignificant vessels or in arteries lacking a severe stenosis. I see young women with atypical chest pain undergoing multiple cardiac imaging studies. At a recent department of cardiology meeting at our hospital, two of the cardiologists expressed their desire to be removed from the ER call roster as hospital work was interfering with their lucrative office practices. As health care reform moves forward, the excesses in imaging will be targeted, but indiscriminately so, as it is no easy task to separate those of us who are using the technology appropriately from those who are not. The expected impact is a 25% pay cut for cardiologists. Could we as physicians have policed ourselves better? Perhaps. The reality is that it is very difficult to reign in the practioners who have evolved into imaging mills or those who deploy stents inappropriately without being accused of stifling competition. Peer review has become a frustrating, politicized process.

Swam at Nitro with Tom, Chuck, Eric, and Jordan. The pool was set up long course. Mondays Coach Mike Koleber, who writes our workouts, serves up a big helping of endurance work, what he likes to call our vegetables. Today I wasn't up for more than soup and crackers, since I am still struggling with the remnants of my bronchitis, but I did what I could.

300 swim, 300 kick, 300 pull
10 x 50 @ 1:00, odds streamline kick, evens teechnique
Main set, a choice of 5 x 400 descend or 20 x 100. Steve, Greg, and David were going to do the 400s on 6:00, so I stayed in my lane thinking the 100s would be easier. Eric led and (to my surprise) went on 1:30. We took a break at 10, then I swam six more and warmed down. Held 1:24s.

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