Tuesday, May 31, 2005
"Trial lawyer advocates often repeat the silly assertion that medical malpractice premiums spiked in recent years because insurance companies had to recoup bad stock market investments. It's an argument refuted often enough before . . ." (via PointofLaw.com)
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"A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. 'Assurance behavior' such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums."
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Simple, yet difficult to enforce, in direct-to-consumer advertising. The FDA made this bed, it's their mess to clean up. Easier to ban DTC advertising outright.
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Come get the weekly best of the medical blogosphere.
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Monday, May 30, 2005
The diabetes drug was a sulfonylurea. Simethicone is given for bloating and gas. Death from hypoglycemia can occur with the diabetes medication.
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"Down the stretch they come.
Attorneys are furiously filing medical malpractice lawsuits in Cook County in a race to beat Gov. Blagojevich's signature on a bill that caps awards in such cases.
Since legislative leaders announced a deal on caps last Wednesday, 58 medical malpractice lawsuits have been filed in Cook County -- three to four times the number normally filed . . .
. . . 'We expected it, we predicted it, we warned about it, and now it's happening,' said Craig Backs, president of the Illinois State Medical Society. 'None of this is the least bit surprising, but clearly this is a good news/bad news situation. The good news is, it reinforces what we've been saying all along. The bad news is, it reinforces what we've been saying all along.'"
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This sex therapist says no: "In my clinical experience, healthy sexual encounters are actually a key part of a sex offender's successful recovery. They teach the sex offender to refocus his desire on an appropriate subject. Some convicted sex offenders have been in treatment for decades, with no recidivism. To deny them access to a normal sex life -- as refusing them treatment for erectile dysfunction would do -- would be counterproductive. Rather than aiding and abetting a sex offender, it's more likely that Viagra is being prescribed to those in a healthy, consensual relationship who are experiencing erectile dysfunction."
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Sunday, May 29, 2005
Spectrum of waiting
Reading these comments got me thinking - Where in the spectrum of waiting are you?Are you, fellow physicians, the type who is always on time, every 15 minutes? Or do you spend as much time as it takes with each patient?
Do you, as a patient, want a physician who runs on time, every time? Or do you mind waiting 1 hour for a visit where all your problems are addressed?
Because you can't have both. It is impossible. Hence, the spectrum of waiting.
A typical visit to a primary care physician's office is allotted 15 minutes. Each physician session lasts 4 hours. Think about that. If the doctor merely spends 5 "extra" minutes with each patient, the last patient of the session will be over 1 hour late. Guaranteed.
Is that acceptable? It depends. Some will find going in and out of a visit in 5 minutes, but on time, to be satisfactory. Others will find waiting 1 hour for a doctor to spend 30 minutes on them to be just as satisfying.
The key as a patient is to find a physician whose view of the spectrum matches yours. Those patients who are unhappy are those who are matched with a doctor with a differing view of the spectrum.
There are doctors who practice at both ends of the spectrum: some like clockwork, running on time; others running late, but taking the time. There are infinitely more who practice somewhere in between.
As a physician, ask yourself where in the spectrum you fit in.
As a patient, ask yourself where in the spectrum you would like your doctor to be.
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"In a paper published in the Archives of Internal Medicine, researchers from the University of Michigan Cardiovascular Center report how their research on heart attack care has been hampered by the national medical privacy regulations under a law known as HIPAA, which took effect two years ago last month.
In all, they write, the changes needed to comply with HIPAA have led to a drastic drop - from 96 percent to 34 percent - in the proportion of heart attack survivors and chest pain patients who take part in follow-up surveys after they leave the hospital. The changes have also dramatically increased in the cost of performing the surveys, and skewed the data because certain kinds of patients are more likely to agree to participate.
Post-hospitalization surveys are crucial to helping quality-minded hospitals like U-M assess and improve their care. Patients' names and other identifying details are removed before their information is entered into a database. Doctors can use the database to find out what treatments and preventive measures help patients most, and what factors worsen their chances. This information helps doctors improve care at their own hospital, and can be shared with others to help them improve too."
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Illinois is the latest state to enter the cap fray: "Now that Gov. Rod Blagojevich and state lawmakers have agreed to try caps to contain the rising costs of medical malpractice insurance and keep doctors in Illinois, even the most optimistic say there is not much to do but hope for the best."
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"The Philadelphia-based board, which has certified tens of thousands of surgeons nationwide, found out last summer that 86 questions used on its 290-question multiple-choice exam were listed on eBay. Questions used on the exam are rotated from a large pool each year."
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Saturday, May 28, 2005
"'People are much more consumerist today,' Dr. Lo said. 'No one wants to wait two weeks to see a doctor. In fact, no one wants to wait an hour in my waiting room. People are much more concerned about getting things done on demand, and they have difficulty finding a primary care doctor who will see them promptly.'"
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"Family medicine is a tough sell. Patient needs are more complex than ever. They're older and not coming through their doctor's door with one ailment. Some have diabetes and heart disease. Others have had a stroke and are now battling cancer. These aren't patients that can be seen and sent on their way at the end of a 15-minute appointment . . .
. . . The fee schedule has also caused family doctors pain and led to a lack of interest in the profession."
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"You start to realize some patients don't give a s---.They don't
appreciate you or what you have to go through. I'm busting my butt, working all hours and getting called at 4 a.m. I have people crying on my shoulder and I have to stick my finger up people's butts -- and for what? . . .
. . . McCarthy knows there are many who will say, 'Suck it up. You make a lot of money and there are plenty of people trying to get by on a lot less.' He knows it's a hard sell.
'It's a lot more money than the average guy makes, that's why I can't complain. But ask your dentist how much they make, or your veterinarian, accountant or lawyer.'
Neither of those jobs come with the same responsibility or the life-and-death decisions that a family practice does, but they're far better compensated."
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"The Food and Drug Administration said yesterday that it had received reports of partial vision loss in 38 men taking Viagra, the impotence drug, and among 4 men taking Cialis, a newer competitor."
It has long been known that Viagra can affect vision in 1 to 10% of cases - mainly color changes, or blurred or increased sensitivity to light. Blindness caused by Naion (nonarteritic anterior ischemic optic neuropathy) is new. Note that the link to Viagra has not been definitively proven yet.
This is another example of how "lifestyle" medications and its overmarketing is not as harmless as it seems. Hopefully, this can be another wakeup call to consumers: think twice about demanding drugs you see on TV.
Update:
Medpundit opines on this.
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"The vast majority of postconcussional syndrome symptoms -- like headache, dizziness and memory loss -- are subjective, which makes it hard for doctors to distinguish feigned or dramatized complaints from legitimate injuries . . .
. . . 'It's a tool for lawyers basically,' he says. 'Patients think they will get a pot of gold at the end of rainbow,' which can lead to 'malingering for money' or overt lying." (via Common Good)
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Friday, May 27, 2005
"To illustrate the mathematics, Al-Aswad disclosed his personal finances: His practice earned about $830,000 last year. Out of that came his insurance costs, rent, utilities, staff salaries and, lastly, his own salary, which was in 'the low $200,000-range.'
He hasn't had a payout for a malpractice claim in 15 years, yet his insurance costs are high  just below what obstetricians and neurosurgeons typically pay. When he received last-minute notification that his insurance costs would be skyrocketing, he faced tough choices.
'I could quit my practice against my wishes or I could retire in a very short period of time, which would compromise my patient care,' he said. 'I couldn't come up with the money, so I was out of business for six weeks. I had to shut down my office. No surgeries. I had to cancel them, delay them or do them early before the insurance ran out.'"
The patients are the ultimate losers as the malpractice crisis continues.
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I've never quite heard of anything like the stories that are coming out down under: "Miach said that around June or July 2003 he decided to ensure that his patients never received surgery from Patel. He said he told Patel he was banned from operating on his patients. Nurses kept vigils over patients to ensure Patel performed no procedures on them when Miach was absent . . .
. . . In earlier testimony, Miach told the inquiry how a young woman developed gangrene after Patel amputated part of her left leg and then failed to check on her for several days.
'There was no follow up, the stitches in the stump were left there for six weeks,' he said in a transcript of the inquiry hearings Wednesday. 'There were areas of infection, areas of gangrene, areas of necrosis.'"
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"A large percentage of all prescribed drugs do not have the desired effect on patients' problems. The many influences on this poor outcome include wrong choice of drug, genetic factors, interactions, non-compliance, and poor drug quality.
A no cure, no pay approach can counter these problems by optimising the effect yet still making the treatment economically feasible. If the drug does not cure, relieve, or prevent the patient's symptoms based on specific clinical measures or visible results, the healthcare system and the patient get their money back. A money back guarantee might also be applicable if the patient suffers adverse effects. This is a previously unseen dimension of rational pharmacotherapy.
Obviously, if a drug company risks repaying substantial sums for a treatment that seems efficacious in clinical studies but does not have the desired effect in daily use, it is an incentive for the company to find programmes that improve compliance, in particular. Programmes to increase compliance are another new dimension that can make a positive contribution to rational pharmacotherapy."
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"The company says that the chemicals break down waste into a 'sweet smelling, inoffensive liquid', which can be disposed of at the end of a journey."
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"At a time when the number of hospital emergency departments has been cut by 14 percent, visits to the ER reached a record high of nearly 114 million, according to Centers for Disease Control and Prevention data for 2003, the most recent data available . . .
. . . Many of the ER visits were made by elderly Americans or the uninsured.
ER visits by Americans over age 65 jumped 26 percent in 2003, and Medicaid patients were four times more likely to seek treatment in an ER than people with private insurance."
We have discussed this ad nauseum here. Again, the culprits are lack of primary care medicine, the "convenience" factor of "instant" treatment, as well as the rise of defensive medicine (better to send everyone to the ER than to risk a lawsuit by treating people over the phone).
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Thursday, May 26, 2005
A mother's plea to her son continues: "To those lawyers who see doctors and malpractice-insurance companies as bearers of deep pockets, blame is key. If you can make people believe that an imperfect outcome is somebody's fault, well then you've just won the lottery. Doctors are running scared because if every outcome is not a good one, if every diagnosis, procedure, consultation, response or reaction does not work out exactly like everyone hopes, then they become the hunted.
What about the fragile nature of life and the well-known truth that there are never any guarantees? Well, in a lawsuit-happy world that may be true, but it's not quite good enough.
As a doctor, you're now expected to be better than God and if you're not, well, the malpractice monster will eat you whole. It will take your heart, your knowledge, your devotion, your sacrifices and throw it in the garbage. It will laugh at the many people you saved. And worst of all, it will take your soul. That very noble soul which drove you to be a doctor in the first place." (via PointofLaw.com)
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The tabloid-like melodramatic statements continue:
Harmful medication-related mishaps cropped up in a quarter of all patients at the Veterans Affairs Medical Center in Salt Lake City, one of the most high-tech hospitals in the country, according to a study published in Archives of Internal Medicine.Yes, medical mistakes are a problem. However, equating every medical mistake to a plane crash is going somewhat overboard.
"If you were on an airplane and a quarter of the time it crashed, that would be a problem," said study co-author Dr. Jonathan Nebeker, a physician at the VA Medical Center.
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More horror stories about Dr. Death.
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"Under the new proposal, backed by both parties and expected to move quickly through the Legislature, individual doctors could be sued for no more than $500,000 in noneconomic damages, and hospitals would face no more than $1 million awards for pain and suffering . . .
. . . The compromise would require for the first time that trial lawyers have a physician vouch for the merit of their malpractice claims before a lawsuit can be filed."
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Wednesday, May 25, 2005
Three more for the roll
Please welcome KidneyNotes, California Medicine Man, and retired doc's thoughts to the blogroll.
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The first is the case of Heidi Baer, "who having failed the medical boards three times is now suing the National Board of Medical Examiners under the Americans with Disabilities Act for not giving her extra time on the exam to accommodate her dyslexia."
The second is a case of a resident "seeking $2.5 million from Norwalk Hospital over alleged overwork and failure to accommodate his attention deficit disorder (ADD). The two sides dispute whether Smith was made to work beyond the 80-hour maximum that is supposed to be placed on residents' workloads."
Even if they win, I'm not sure what kind of message this sends. As one blogger puts it, real life in the medical world will not adapt to them:
Her actual problem, however, is far more serious. Doctors are among the most time-pressed professionals out there. (How long did your doctor spend on you last time you went to see her?) Emergencies are routine. Ms. Baer isn't going to be able to slow everything down just because she's a slow reader.(via Overlawyered)
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"Robert Berenson, a senior fellow with the Urban Institute and a medical doctor, says much of medicine can be done simply by getting a verbal description of the patient's condition and health history. While it's best to know the patient beforehand, doctors quite often provide treatment for patients they've never met.
'If you're covering your partner's patient, you've never met them and you don't have access to their chart because we don't have electronic medical records,' Berenson says. 'There's nothing radical about people diagnosing over the phone. What makes this interesting is people taking a chance on a doctor they don't know.'"
A huge liability risk that these docs are taking.
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"Some damages seem inevitable, as William Beaumont Hospital admits its fault in the fire. The hospital's lawyer, Keefe Brooks, said it is rare for a defense lawyer in a civil trial to ask for damages.
'Yes, it's true that William Beaumont Hospital caused that fire,' said Brooks. "William Beaumont Hospital caused Nathan to suffer the burns.
'On behalf of William Beaumont Hospital, we apologize to the Laporte family,' he said turning to the parents, Craig and Shelley Laporte of Macomb, adding that he hoped the jury would award an appropriate damage."
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More lawyer soundbites. I'm not making $1 million a year, and I don't know very many physicians who make even close to that.
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Can this be the birth of a co-pay in Canada?
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I'm not sure what the rate of this particular complication is. With the advent of MRIs, the use of myelograms has steadily decreased.
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"'We were seeing these patients dying every day and we couldn't do
anything,' Toni Hoffman said as she choked back tears. 'We just
thought, what on earth could we possibly do to stop this man.' . . .
. . . Hoffman said the man dubbed Dr. Death by the Australian news media would regularly stalk the intensive-care ward looking for patients to operate on - but his high level of complications led the nurses to take drastic action."
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"Dr Anna Gregor, the country's 'cancer tsar' and the Lothians lead cancer clinician, believes an extra two per cent tax on fast food could encourage people to adopt a healthier diet.
She said this in itself would help boost cancer survival rates and the extra revenue could be used to promote healthy eating initiatives."
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Most people only remember the headlines. Shame on you WebMD for pumping up such ridiculously preliminary cardiovascular data for Levitra:
To see if these drugs might have other long-term health effects, Sommer and colleagues studied men with benign prostate symptoms. Some of the men got Levitra, an erectile dysfunction drug, once every day. Other men took Levitra only when they desired sexual intercourse.
After three months, the men getting Levitra every day had:
* Just as good relief of erectile dysfunction as the Levitra-on-demand men
* More improvement in tests for blood flow, which indicate healthy blood vessel function
* More improvement in prostate symptoms
But it's not yet time to start popping those little pills along with your daily vitamins. The study findings, Sommer and colleagues note, are preliminary.
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"It was one of those moments that send shudders through even the most experienced physician.
Dr. Staci Fischer was already treating one patient at Rhode Island Hospital battling a virulent infection just 2 1/2 weeks after receiving a new kidney. He had fever and diarrhea and other symptoms that made Fischer think the man had contracted hepatitis.
Then, a few days later, Fischer encountered a second transplant recipient at the Providence hospital whose health had deteriorated precipitously. Like the first patient, the second had received a kidney, and, it turned out, the organs had come from the same donor. The patients' sudden illnesses were distressingly similar . . .
. . . Fischer's call started an investigation that led to the discovery of two other transplant recipients gravely ill with mysterious infections at hospitals in Boston. In the end, all four patients, including three who died, would be connected to a single donor whose pet hamster carried the same type of virus that had infected the transplant patients."
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Tuesday, May 24, 2005
"The silence in America on the issue of the pope's 'comfort measures only' care at the end stands in sharp contrast to the national shouting match and political seizure that scarred the last days of Terri Schiavo's life. Despite the obvious withholding of potentially life-saving treatment from the Pope, newspaper columns and talk show hosts calling for 'saving' the pope were nowhere to be found. The U.S. Congress did not try to subpoena the dying pontiff and his doctors to testify. U.S. Senate Majority Leader Dr. Bill Frist did not diagnose the pope's condition from afar and suggest the pope's doctors were making the wrong diagnosis. U.S. Rep. Tom DeLay did not suggest that the pope's caregivers were killing the patient pontiff, or that we should intervene with the therapeutic cavalry because the pope was lying there wanting to be saved but unable to say so. President Bush flew in only to the funeral, not to the rescue. The most beloved man on earth died without all the care he could have had and no one sued anyone."
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"An Encinitas orthopedic surgeon has been ordered to pay $175,000 for his endorsement of a device that claimed to tone muscles by sending an electric current into the users' body, attorneys announced Monday . . .
. . . According to the City Attorney's Office, Skyhar agreed to place his name and quotes on AbEnergizer packaging, and participated in an infomercial aired on television nationwide."
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"The researchers found that several factors were associated with the likelihood that patients would keep taking the medicines.
At the top was the number of other prescription drugs already being taken. The higher the number the greater the chance that the patients would stop the new medicines. So the researchers suggested that doctors consider stopping some prescriptions.
The study also found that when the blood pressure and cholesterol drugs were prescribed near the same time, the compliance was greater."
Consider the amount of medications you need after one has a heart attack: aspirin or Plavix, a beta-blocker, an ace-inhibitor, and a statin. All 4 medications have been shown to be life saving post-MI. If you have diabetes on top of that, that's another 1-3 potential medications.
As newer medications come into play - more patients are going to be saddled with "must-take" medications. Systolic congestive heart failure is a good example. Way back when, we used to treat this with digoxin and diuretics. Now, a typical regimen would include an ace-inhibitor, beta-blocker, spironolactone (in severe cases), and then perhaps digoxin.
There is only a mortality benefit if the patient takes the mediation. The advent of combination pills may be an answer to help compliance.
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Come get the weekly best of the medical blogosphere.
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Monday, May 23, 2005
"For the study, published online Monday by the American Heart Association's journal Circulation, researchers analyzed reports of side effects sent to the FDA for Crestor and compared them to the rates during the same time period for three other statins: Lipitor, Zocor and Pravachol.
'What we've shown is that amongst this family of drugs, Crestor has a poorer safety profile, but that the overall rate of adverse effects is still quite low,' said study leader Dr. Richard Karas, director of the preventive cardiology at Tufts-New England Medical Center in Boston."
Statins are still an invaluable class of medications proven to save lives. However, I would reserve Crestor for those with hyperlipidemia refractory to other medications.
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"According to Hevesi, the problem is an unintended consequence of a 1998 directive from federal officials telling states that Medicaid prescription programs must include Viagra. His office discovered that the state was helping sex offenders pay for Viagra by checking Medicaid pharmacy expenditures against the states sex offender registry."
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"I was curious about this cutting edge test that the author classified in the same category as, say, cholesterol profiling. When will patients begin asking for this test on their own? When will lawsuits be filed for adverse drug reactions that could have been potentially prevented by CYP450 testing?"
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"But experts fear people are getting scans they don't need, padding doctors' wallets and exposing themselves to radiation unnecessarily. And rising costs always raise the question of how much our health care system can afford."
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Sunday, May 22, 2005
With all the recent woes of pain management doctors, it seems like it hasn't affected many physicians' prescribing practices.
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"'Can you text me my result?' I asked my colleague. She looked horrified. As breast radiologists and clinicians working in the screening service our most difficult job is to give bad news. But by text? Suddenly with black humour we could imagine the headlines, 'Patient receives diagnosis of breast cancer by text message.'"
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Saturday, May 21, 2005
Here's one: "I'd also include a hefty carrot for doctors to keep their fees down: Patients taken on an assigned fee basis would give up their right to sue for malpractice. Instead, they'd agree to participate in a no-fault system, in which an expert panel would determine compensation for patients who have suffered preventable medical injuries."
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"You're obligated to stay informed about current studies concerning the safety and efficacy of all drugs that you are currently prescribing or have prescribed in the past. That means reading journals, attending CME courses, and heeding FDA warnings. Don't assume that you're protected from liability if there's no FDA recall. If the FDA or the medical literature warns of potentially harmful side effects, the standard of care requires you to take a proactive approach with your patients."
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"It could only happen to a gangster - or to an ED doctor like me. Three minutes ago, I'd never seen the guy. Now, with one slash of the scalpel, I slit his throat. From start to finish, it takes fewer seconds to do it than to tell you about it."
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"Even allowing for an expected correlation between the two variables -- persons with more serious injuries are presumably more likely to retain lawyers -- legal representation appears to have an independent effect in prolonging the process of recovery." (via Overlawyered)
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"He argues that regulations that create long waiting times for surgery contradict the constitutional guarantees for individuals of "life, liberty and the security of the person," and that the prohibition against private medical insurance and care is for sick patients an "infringement of the protection against cruel and unusual treatment."
He believes that Canada is disallowing the basic contract rights of doctors and patients, and that the country would serve the sick much better if it had a parallel private health care system, as in France and many other industrialized countries."
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"The baby, who was born with a congenital heart defect, was taken to Leicester's Glenfield Hospital less than two weeks after his birth in March 2002 after experiencing breathing problems.
He died a few days later after being given the drug Digoxin, which slows the rate of heartbeat.
One of the doses was calculated at 220 micrograms when the correct amount should have been 22 micrograms."
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I believe it's the only department of its kind. Even though it sounds like an official second opinion department, I'm all for giving the patient more autonomy in their medical decisions.
However, not all are enthused: "The center has met resistance, however. Some comes from physicians wary of decreasing the number of procedures they perform. Others see it as a burden on their time or an infringement of their autonomy."
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Friday, May 20, 2005
"The doctors all failed to recognize a 1-centimeter lung lesion on a chest X-ray taken of the Harvard University professor in February 2001, according to Alex MacDonald, the lawyer for Gould's survivors.
Thirteen months later, after another chest X-ray was taken, the lesion had grown to 3 centimeters and the cancer had spread to Gould's brain, liver and spleen, MacDonald said . . .
. . . 'We have a film that clearly shows a lesion that was missed by three doctors, and it should not have been,' MacDonald said. 'If it had been recognized, professor Gould would still be teaching at Harvard College today.'"
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Interesting entries and frequently updated.
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