Wednesday, June 30, 2004
A sign of the times
An ethics professor takes an interesting look at how elitist the US health care system is becoming. On one hand, we have concierge practices:Now, one might wonder why it is necessary to pay a bounty to get a doctor to call you back, especially if you are already paying through the nose to belong to a managed care plan. The answer is that under the watchful eye of managed care and insurance companies, the quality of care has gotten so awful that doctors sneeringly refer to it as "hamster care." Only those patients who pay more are going to get treated by the "concierge" doctors who get off the daily treadmill and practice good medicine, providing the sort of attention and service that our parents and grandparents took for granted.
On the other, we have what's happening to the Medicaid program Tennessee:
Historically, decisions about what drugs or treatments a patient received were chosen by a standard of care known as "medical necessity." Doctors determined what was medically necessary based on local standards of medical practice, and if they did not practice according to this standard they could be found guilty of malpractice. TennCare does away with the established standard and replaces it with a new one - "adequate care." If a bureaucrat in the Tennessee department of health thinks a low-cost drug or treatment, or even no treatment at all, is "adequate," then that is what TennCare will provide.
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What discounts?
It seems the effect of the Medicare drug discounts was simply higher drug prices. The more things change, the more they stay the same.
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Tuesday, June 29, 2004
The myth of July syndrome
The NY Times today writes about the so-called July syndrome - the time when the new house staff start at teaching hospitals across the country. There is no data to support worse patient outcomes in July - although I can certainly remember the potential for disaster.My very first day was being the night-float intern at the former Boston City Hospital. This meant cross-covering every medical patient in the hospital, with tasks ranging from drawing blood cultures and putting in IVs to dealing with psychotic outbursts. And to think I was a medical student just 24-hours before. Talk about trial by fire.
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Ideal medicine vs real-life medicine
Refraining from testing and evidence-based testing is nice, but difficult in today's practice environment:In one study in which Dr. Kroenke said he examined 500 patients with physical symptoms, 70% of all subjects improved two weeks after seeing a primary care physician. While symptoms persisted in about 25% of patents, follow-up studies showed that serious diseases not suspected during initial evaluations rarely emerged after one year.
The lesson, said Dr. Kroenke, is that a full battery of testing is often not the solution to common complaints. "Additional testing is quite often negative, so we want to avoid repeating workups and referrals," he explained.
In court, it's much more difficult to defend not doing a test, than to defend doing a (likely unnecessary) test with a negative result. So far, physicians are not being sued for doing too much testing, and until that changes, there will continue to be a disconnect between real-world medicine and evidence-based medicine.
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Liability surcharges
Seems like practices who have a liability surcharge may become increasingly common:Physicians gathered at the AMA Annual Meeting last month explored a variety of options for immediate relief for a profession besieged by increasingly unaffordable medical liability insurance premiums.
The hottest topic of discussion: liability surcharges. The idea is that physicians would tack a charge onto patients' bills to help offset their insurance payment. Low Medicare and even lower Medicaid reimbursement rates combined with managed care contracts that lock in fees have left them no way to recoup increased overhead, physicians said.
It is unfortunate that the lack of tort-reform progress and reimbursement solutions are resulting in passing the buck to the patient. To use a sports analogy, this is akin to contract bargaining between the owners and players, with the fans being the biggest losers.
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Statins and macular degeneration
One of my patients this morning wanted a statin prescribed to ward off macular degeneration. She had perfect cholesterol. I wasn't aware of any trials connecting the two and told her I'd look into it. Here's what I found:A new study from UAB indicates that patients who take cholesterol-inhibiting drugs known as statins are less likely to develop symptoms of age-related maculopathy (ARM), better known as macular degeneration. The findings suggest a possible association between ARM and cardiovascular disease.
Interesting connection, but certainly more research is needed before I'll give the statin for this reason. As an aside, seems like statins are the aspirin for the 21st century.
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A nice overview . . .
. . . to medical weblogging can be found on Medscape today (via Tales of Hoffman).
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Monday, June 28, 2004
Bribery
I was just in NYC this past weekend and was going to comment on this NY Times article, but Nick at Blogborygmi has eloquently summarized everything up.
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As follow-up . . .
. . . to physicians denying treatment to lawyers, Medpundit gives an insightful opinion on this desperate tactic.
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More malpractice ranting
Nothing like coming back from vacation and seeing more inflammatory articles on the malpractice controversy. Medrants summarizes some of the more recent articles.Update:
After catching up on some weekend reading, our friend Medpundit has also chimed in on the recent ignorance by the NY Times and the esteemed Mr. Herbert.
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Sorry for the dearth . . .
. . . of posts in the past few days. My blogging time will be limited in the next week or so, but I'll link to some interesting reading meanwhile.
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Thursday, June 24, 2004
Response to the NY Times malpractice op-ed
There has been much discussion on the recent NY Times piece on "Malpractice Myths", seen here at Medrants. Now comes some more criticism from the law world, highlighting the obvious ignorance of the article (via Medpundit).
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Wednesday, June 23, 2004
The switch to EMR
So the big deal in my practice is the transition to an EMR in the upcoming months. Finally. Our administration has chosen the HealthMatics EMR by A4 Health Systems.The plan will be to carry these laptops into the exam room, and in an ideal situation, directly enter notes into templates while doing the history.
Anyone have any experience with this system? Any tips or pitfalls to look out for?
Posted by Kevin |
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Tuesday, June 22, 2004
Unnecessary PAP smears
Stories are coming out regarding the recent JAMA article concluding that the USPSTF recommendations on PAP smears are being ignored:Twenty-two million US women 18 years and older have undergone hysterectomy, representing 21% of the population. The proportion of these women who reported a current Pap smear did not change during the 10-year study period. In 1992 (before the US Preventive Services Task Force recommendations), 68.5% of women who had undergone hysterectomy reported having had a Pap smear in the past 3 years; in 2002 (6 years after the recommendation), 69.1% had had a Pap smear during the same period (P value for the comparison = .22). After accounting for Pap smears that may have preceded a recent hysterectomy and hysterectomies that spared the cervix or were performed for cervical neoplasia, we estimate that almost 10 million women, or half of all women who have undergone hysterectomy, are being screened unnecessarily.
Is it habit? Is it patient expectation? Or perhaps physicians are being defensive - maybe the lawsuit regarding PSA screening is in the back of their minds.
Posted by Kevin |
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Billing for sex
Lest I be accused of taking a continual pro-physician bias, comes a story that brings shame to our profession:An Oregon doctor, who had sex with a patient and then charged the state about $5,000 for his "treatments," has been jailed for 60 days and stripped of his license, officials said on Friday.
Dr. Randall J. Smith, 50, told the woman that massaging her "trigger points" would ease her pelvic pain. The treatments led to sexual intercourse and Smith billed the Oregon Health Plan for the 45-minute sessions at the Adventist Health Medical Group clinic in Gresham, Oregon, near Portland.
Posted by Kevin |
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On mammograms
The mainstream press has gotten hold of the recent MGH study detailing that only 6% of women obtain a screening mammogram yearly during a 10-year period. With the barriers today to mammogram access, I'm not sure that improvement is on the horizon.
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An impossible standard
Medpundit writes an insightful piece on how recent lawsuits have equated risk with harm.
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Monday, June 21, 2004
Money talks
Paying patients to lose weight. It's the American way:One doctor paid $1,044 to 150 of his patients who lost weight . . . The patient with the greatest weight loss, a 51-year old woman, took off 35 pounds and will get a vacation to Las Vegas, a bonus prize Dr. Chemplavil threw in as an added enticement.
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Sunday, June 20, 2004
A sign of things to come?
We have concierge practices, now people can pay extra for "priority access" at emergency rooms:The 95-year-old financially ailing Southampton Hospital - the only serious medical emergency center on the South Fork - is offering a plan aimed at wealthy summer visitors whose primary doctors are back in Manhattan and out of reach, presumably along with the hospital's sense of propriety. For $6,000 per family, or $3,800 for individuals, not including doctors' fees, cardholders in the Southampton PLUS plan are entitled to "priority access" to medical care at the hospital from May 28 to Sept. 26.
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New Hampshire bike week and helmet laws
This week is Bike Week in New Hampshire. It amazes me as I drive home how many helmet-less motorcyclists there are around here, zooming along at 70+ mph. As you may know, there is no helmet-law here.Consider the following from the BMJ:
Deaths on motorcycles have increased 54% since 1997. As soon as helmet laws are reversed or weakened in a state, injuries and fatalities go up. Per mile traveled, the number of deaths on motorcycles is more than 25 times greater than that in cars. Much of this difference is due to the unique vulnerability of motorcycle riders, especially when they are not wearing helmets, but some of it is because of motorcyclists' lack of visibility to other drivers.
Live free or die indeed.
Posted by Kevin |
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Saturday, June 19, 2004
Capitalism and the health care system
The Atlanta Journal-Constitution editorializes on how capitalism is one of the driving forces behind our broken health care system:We now have a health-care system whose primary mission is not delivering health care. Instead, insurance companies, pharmaceutical companies, medical device manufacturers and, in fact, many hospitals exist to make money. That's their first priority, and also their second and third priority. The product they sell happens to be improved health. But they jack up the prices on the product and restrict it to those who can afford it.
. . . As more and more working Americans find themselves without health insurance, our faith in the ability of capitalism to provide a fundamental asset of American life is being sorely tested. Sometime in the next decade, we'll be forced to admit that government will have to step in and shore up the safety net by guaranteeing basic health care to all Americans.
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Follow-up on the South Shore ER
For those who have been following the incidents at the South Shore ER, written here earlier this month, the Boston Globe writes about the status of the investigation. As an aside - an 82-bed ER is bigger than some of the hospitals that I round at.
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More on ER (mis)use
Medpundit has commented on the ER (mis)use piece written earlier this week, emphasizing the convenience ("In fact, you don't even have to walk to your tests. You get rolled to them in a wheelchair or gurney." - how true). Perhaps people are willing to wait the 5-6 hours in exchange for a second opinion, or in some cases a specialist evaluation. Beats waiting months.A recent radiologist commenter had this to say:
. . . clearly a large part of the increase in ER visists is clearly the increased convenience, however, in recent years it has clearly become apparent that the ER is in a large part covering the off hours of the many primary care and specialist practices affiliated with that hospital.
It is interesting to note that when I now call doctors' offices off hours for an emergency interpretation, there is almost never a service on call that will take the message and contact the doctor on call. Instead, most practices now say, "If this is an emergency, please call 911 and go to the ER". There is no option for patients to reach their physican practices on call on off hours anymore. Thus they use the ER for all complaints.
I cannot comment on how other practices work around the country - just in my area. My particular 5-person group has 24-7 physician coverage by pager. Whenever the ER wants to consult on our patients, a simple call should be able to reach a physician within the group. More difficult is the telephone consultation. When a patient calls on the phone off-hours, I would have a pretty low threshold to send them to the ER. Too much risk in giving advice and treatment over the phone without actually seeing the patient.
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A professor of law on malpractice reform
Today's Boston Globe contains an interesting piece on malpractice reform from a professor of law at Columbia University. One nice analogy:Current practices make no more sense than asking airline pilots to guarantee safety for the entire aviation industry, and forcing those who fly the most dangerous routes to compensate injured passengers from their personal paychecks.
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Friday, June 18, 2004
"We'll get you one way or another"
What a quote from the president of the Academy of Florida Trial Lawyers in response to the increasing number of physicians going without malpractice insurance (i.e. "going bare"):'You can't hide all of your assets and you can't hide all of your wages forever. One way or another, we'll find a way to represent these medical malpractice victims because they deserve it,'' said Alexander Clem, president of the Academy of Florida Trial Lawyers.
Posted by Kevin |
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"Defensive wording" in medical guidelines
Medical Economics discusses the use of clinical guidelines in malpractice litigation. One interesting point is raised regarding whether new guidelines are being affected by the current malpractice atmosphere:. . . as trial lawyers are using guidelines more in court, the organizations writing them are changing their motives. The American College of Obstetricians and Gynecologists, for example, has recently come under fire from plaintiffs' lawyers . . . for issuing guidelines that seem more protective of doctors than patients. The College's guidelines, they say, appear designed to shield doctors from liability rather than to improve care . . .
. . . each time an organization's guideline writers see a plaintiffs' attorney win a case by proving that a doctor didn't follow one of their guidelines, they may simply weaken the guideline. . . guidelines of an earlier era might have stated, "In this situation, the doctor should do the following . . . ." Now, the guidelines are written much more defensively, carefully avoiding prescriptive language. They are worded to say something like, "In this situation, the doctor might consider doing the following . . . . "
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Thursday, June 17, 2004
Winning Gmail entry #2
Our second winning entry is a story from a paramedic:A late-fifties male gets up in the morning [wife’s still sleeping] to go to the bathroom. He’s overweight, smokes like a chimney, and is now grunting away - trying to push out the pound of steak he ate for dinner last night. While he’s doing that, the pressure he places on his bowels produces a sudden drop in his heart rate, with a corresponding drop in blood pressure. This is known as ‘vagal-ing out’ - as the vagus nerve responds to such stimulus by dropping the heart rate. The man gets dizzy, and falls off the can in mid-shit. This is what I call the classic ‘Elvis’ presentation: man on bathroom floor, boxer-shorts down to his ankles, flopping around and leaving skid marks on the floor so wide you’d have thought a 747 landed nearby.
Now his heart *could* at any moment increase its rate - but since his heart is soooo tired after all those years, it decides to pump at this rate for a while - ‘catch a breather’ so to speak. Ironically, since the heart isn’t pumping enough to circulate blood and oxygen efficiently, the heart itself does not receive enough blood and oxygen to continue beating - so it quits altogether.
Anywhere from several minutes to several hours later, this man’s wife wakes up - and follows the ‘I had steak for dinner last night’ smell to the bathroom, where she finds hubby. Naturally, you’d think her first reaction is to dial 911, to get some help for him. Noooo, wrongo. You may pick from the following options:
1) She yells “Ralph - wake up.”
2) She notices his boxers down to his ankles, and pulls them up.
3) She splashes cold water on his face.
4) She yells “Ralph - wake up” again, just in case he didn’t hear her the first time.
5) She genuflects, makes the sign of the cross, and throws in an ‘Our Father’ for good measure.
6) She calls the family doctor - to ask what to do.
7) She calls the family priest - to ask what to do.
8) She calls another family member - to ask what to do.
9) She does all of the above - then dials 911.
10) Any combination from above.
By the time an ambulance gets dispatched to a cardiac arrest, things look pretty dim.
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Winning Gmail entry #1
Our first winning entry is a story from a grizzled resident:A lot is on my mind these days. I am thirty years old, I have a one year girl who is turning into an Olsen Twin with melodrama substituted for ‘acting’. I just had a new baby boy 7 days ago who has decided to make me relive my intern year all over again; sleepless nights and a continuous hazy filled days. And I now have to find time to end my last residency shift on the 30th of this month, pack 3 years worth of life, 2 babies, and a wife, and travel to the ridiculously expensive Boston for my fellowship training. Of course, I have to wake up and start my new job with a ‘smile’ on my face as if I had a pleasant time between jobs and restful sleep. And this is all good news.
So then what can be the bad news. Well let’s say that I am 1 year away from full exposure. 1 year aware from facing patients who you spend years taking care of, only to turn face and join any malpractice happy lawyer. Is this what medicine has turned into? Instead of worrying about just optimally treating my patients, I have to worry about survival. I feel I have to be suspicious of every patient who walks through my door.
Confusion, fear, hesitancy. This is the medical world that awaits me.
Love, compassion, support. This is the home I leave every day for the world.
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Gmail invite status
It seems like Google is giving away Gmail invites like candy. I now have 7 (!) to give away. Instead of posting the top three stories, I'll be giving away the invites on a rolling basis. Again, I'll accept anything medically-related that's interesting or entertaining - just email me your submission.
This will go on until I run out of invitations. I'll start posting some winning submissions later today.
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Canadian pharmacies safe
Despite the current controversy on importing medications, it seems a recent report has observed that Canadian pharmacies are pretty safe. In fact, some have stricter standards than US-based pharmacies:Despite safety concerns voiced by opponents of prescription drug imports, congressional investigators said they encountered few problems with medicines purchased from Canadian Web sites.
In some instances, Canadian online pharmacies had stricter standards than those in the United States, according to the report released Thursday by the General Accounting Office.
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On emergency room (mis)use
As a follow-up to what I wrote last week on the ER stories near Boston comes this report. Most of it we know already, but it's nice to see some concrete data:One-fifth of patients coming to the ED did not have conditions requiring emergency care, and another one-fifth had urgent conditions that could have been treated in a primary care setting, the report shows.
Uninsured and Medicaid patients in some communities might have to wait six months or more for an appointment with a specialist. But if they go to an ED, they get all their needs met in one place at any time.
"The convenience of the emergency department really offsets the long waits that are associated with it" . . .
The last point has resonance. The key is primary care and specialist access. When I work in ED fast-track, there is a good proportion who come in for medication refills and the like - simply because they can't contact nor see their primary care physician.
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No waiting rooms
Some practices are eliminating waiting rooms altogether and bringing patients directly into the exam room. It seems like shifting the waiting from one place to another, but patients feel they are one step closer to seeing a physician.
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Wednesday, June 16, 2004
Latest on the uninsured . . .
Almost 1 in 3 had no insurance for at least one month in the past two years. Unacceptable.
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Tuesday, June 15, 2004
Physicians vs lawyers
More stories are coming out that demonstrate physicians taking the malpractice crisis in their own hands.
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AMA on emergency contraception
As a follow-up to what was written here last month, the AMA chimes in with their opinion.
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Maybe this is what we need . . .
. . . to help curb cigarette use. Shock tactics. I love it.All cigarette packs sold in Singapore will soon carry gruesome messages including images of a cancerous lung and a sliced brain oozing blood to scare smokers into quitting, health officials said.
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Monday, June 14, 2004
An extreme response to malpractice
Here is one physician's extreme response to rising malpractice costs. It surely was meant to be inflammatory. The fact it was allowed to get this far reflects the deep frustration within the physician community. Some doctors are taking matters into their own hands.
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Sunday, June 13, 2004
Interested in a Gmail invite?
I have three invitations to Google's upcoming Gmail service. It is currently in a beta-test stage, but many people are taking advantage of the invitation to secure their own preferred addresses before the service goes public.
If you're interested, email me an interesting medically-related story, anecdote, editorial or opinion. It could be from a patient or provider perspective. At the end of the week I'll post the three most interesting entries and give each of the three a Gmail invite.
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Should psychologists be able to prescribe?
From today's Boston Globe comes a story detailing the controversy about allowing psychologists (non-MD's) to presribe medication. The state of Louisiana recently passed a law allowing this to happen. Here are some excerpts detailing the arguments on both sides:. . . [the] president of the American Psychiatric Association, calls the Louisiana law ''really scary," saying undertrained nonphysicians will harm, and perhaps kill, patients. ''Without a doubt, they'll make mistakes," . . .
. . . Louisiana psychologists would have to pass a 400-hour psychopharmacology program to prescribe.
. . . Psychologists argue that granting prescription privileges will alleviate shortages of psychiatrists. In some rural states, including Louisiana, patients who might need medication wait months to see a psychiatrist.
. . . But critics say medical psychologist programs are a drop in the bucket compared with the training doctors must undergo . . . the psychologists' 400-hour curriculum would cover only five weeks of the typical 80-hours-a-week medical school residency.
. . . Psychiatrists also say that many of these programs depend heavily on distance learning, in which students learn by computer and meet through chat rooms.
. . . Proponents say the Louisiana law includes an effective safeguard against error: Before prescribing a drug, the psychologists must consult with a physician, who can veto the prescription if it seems unnecessary or incorrect.
My bottom-line take: there should be no way that psychologists be able to prescribe. People go to medical school for a reason - a quickie 400-hour course does not replace a medical school education nor a psychiatry residency. It would be akin to going to a dentist and having the hygienist perform the tooth extraction. Patients deserve better. If psychologists want to prescribe, go to medical school. Period.
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Saturday, June 12, 2004
Against drug company manipulation
Nice to see the AMA taking a stand against the sometimes biased drug company study data:Proposals facing the American Medical Association include a measure seeking to make all drug study results public, even unpublished research funded by pharmaceutical companies that might reflect poorly on their products.
. . . It is critical for doctors to have all information on tested drugs so they can make informed prescribing decisions . . .
. . . Drug companies aren't required to publish study results, and medical journal editors "are at the mercy of what is sent in the mail" . . .
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Friday, June 11, 2004
Magnets for osteoarthritis?
A few weeks ago, a patient who sells these things gave me some magnet wristbands to try. They are meant for acute pain and osteoarthritis. I was dubious of their claims and was not aware of any supporting evidence. I recently came across this recent POEM from the Cleveland Clinic which cites a small study on this topic.
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Worsening mammogram access
Medpundit gives a bottom-line take on why there is worsening access to mammograms today. I completely agree.
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Thursday, June 10, 2004
A tale of two patients
"On Being a Doctor" is one of my favorite journal reads from the Annals. This particular one is particularly poignant.
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Novel cure for asthma?
I don't think this is an evidence-based approach for asthma.
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Wednesday, June 09, 2004
A common-sense solution
This solution to rising malpractice premiums makes the most sense to me.
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Tuesday, June 08, 2004
A suit on ignored medical advice
An Alaska surgeon was sued because a patient ignored his advice to go to the emergency room. Again - a failure of personal responsibility has resulted in yet another malpractice suit. Fortunately, the jury was sensible and ruled in favor of the physician. I still have hope yet.
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No-fault malpractice
Medical Economics this month discusses the feasibility of no-fault malpractice, similar to automobile accidents and workplace injuries. A fascinating read.
Posted by Kevin |
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Condoms on-call
Caught without contraception? No fear - in Sweden, they have the condom express to help curb the rise of chlamydia in that country.
Posted by Kevin |
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Monday, June 07, 2004
Statins and cancer
So the big story today is how statins can ward off cancer. This is a classic case of media hype of questionable data that was discussed last week. In this case, the data is observational and can hardly be used for any recommendations. Even the article itself recognizes this (of course, not in the title):However, researchers seem unanimous in saying the evidence is still too weak to recommend taking statins for cancer-prevention alone . .
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Saturday, June 05, 2004
C Difficile claiming lives in Canada
There seems to be an emerging problem with C Difficile in Canada, claiming "more lives than SARS". Typically, this is an antibiotic-associated infection treated with flagyl or oral vancomycin. Oral bacitracin and lactobacillus for refractory cases are being studied.
Posted by Kevin |
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