Kevin, M.D. - Medical Weblog

Not happy with his malpractice defense, a doctor sues the law firm that defended him.

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The next part of the NY Times' excellent "On being a patient" series: Why doctors' don't listen.

Ms. Wong had come across a bane of the medical profession: the difficult doctor. These doctors may be arrogant or rude, highhanded or dismissive. They drive away patients who need help, and some have been magnets for malpractice claims.

And while such doctors have always been part of medicine, medical organizations say they fear that they are increasingly common - doctors, under pressure to see more patients, are spending less and less time with each one and are replacing long discussions with laboratory tests and scans - and that most problem doctors apparently have no idea of their patients' opinions of them.

Patients usually do not confront doctors. Instead, most rant to friends or family members about their experiences or simply change doctors. But in most areas of the country, there is an abundance of patients. If a few patients leave a medical practice, plenty more can take their place, so doctors may never even know what their patients think.

Pretty easy to see why. Doctors are rewarded (i.e. paid) by quantity. There is incentive to order tests and perform procedures rather than spending time with the patient. With Medicare reimbursements being pressured daily, the government is essentially forcing doctors to practice conveyor-belt medicine.

Fix the reimbursement system, and you'll see these communication problems magically vanish.

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That lovin' feeling: It only lasts a year. "The powerful emotions that bowl over new lovers are triggered by a molecule known as nerve growth factor (NGF), according to Pavia University researchers.

The Italian scientists found far higher levels of NGF in the blood of 58 people who had recently fallen madly in love than in that of a group of singles and people in long-term relationships.

But after a year with the same lover, the quantity of the 'love molecule' in their blood had fallen to the same level as that of the other groups."

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HIV-infected babies are often abandoned in Russia. "Most children of women with HIV aren't born infected, but they cannot be reliably tested for the virus until they are 15 to 18 months old, and many mothers abandon them in the belief that they and the babies will soon be dead. Other mothers are drug users and cannot take proper care of their children.

Russian law requires abandoned children to spend their first three years in so-called 'baby houses,' where they are taught to walk, talk and interact with others."

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American College of Radiology to Tom Cruise: "The ACR is concerned that Tom Cruise has been badly advised regarding the use and potential abuse of ultrasound. There are many abnormalities that may be missed by the untrained eye. Also, if it is not medically necessary, the use of ultrasound raises unnecessary physical risk to the fetus." (via KidneyNotes)

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The third Vioxx trial: "It didn't matter what the dose was. It doesn't matter how long you took it."

News to me. (via PointofLaw.com)

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Why is it that doctors will never tell you up front that something is going to hurt? Michelle reveals what doctors really mean.

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$36.5 million. Still wonder why C-section rates are so high? "The jurors found Doelger failed to interpret strips from a monitoring device that indicated the fetus was in distress, court records show. The difficult delivery continued so long, the fetus suffered from a dangerous increase in blood acidity; the child should have been delivered by Caesarean section long before it was, the jurors concluded.

The hospital was deemed liable, the jury said, because its nurses failed to alert Doelger to the distress signals, the records show.

'Had the Caesarean been performed even 30 minutes earlier, Nicholas would be fine today,' she said. 'It was just tragic that it happened that way.'"

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You're fired: A Long Island hospital is going to replace most of its ER staff. "The hospital's 20 full-time emergency room doctors specialize in non-emergency fields, including internal medicine, surgery, gynecology or pediatrics. Only two doctors have the training and certification in emergency medicine that would now allow them to stay.

Asked whether the doctors would be offered other jobs in the hospital, Kane said, 'I don't know that there will be vacant positions elsewhere that they would qualify for.'"

Update:
GruntDoc gives his take.

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A physician who treated bin Ladin says he would treat anyone. "Aziz bristled when asked whether he knew the al-Qaida leader's whereabouts.

'I have no idea, and I couldn't care less,' he said. 'If you treat somebody just once, you don't become his doctor. The majority of the people in the world hate George Bush, and if I was asked to treat him, I would do that. I have taken a Hippocratic oath. I can't refuse treatment to anyone.'"

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Increasing Medicaid reimbursement is a positive step in improving access.

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Miss HIV: Russia is considering holding a beauty contest for HIV+ women.

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When is the best time to persuade smokers to quit? Right after a cancer diagnosis:

Studies show that using the moment of diagnosis to initiate smoking cessation programs can help up to 70% of patients quit, she and her colleagues wrote, compared with the 20% success rate that is usual in the general population, the researchers argue.

I wonder if the same is true after a heart attack.

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Some with spinal cord injuries are travelling to China for experimental surgery. "Paralyzed in May 2003 while performing a backward flip in a cheerleading stunt, Laura, 16, underwent experimental surgery in China late last year and pursues therapies she and her parents, Daryl and Melody, find promising.

Her story illustrates how some people with spinal cord injuries and their families are devising their own solutions and remedies, even building expensive home gyms. Much like cancer patients and thousands of others who search abroad for cures and treatments, they face questions and skepticism from the medical establishment."

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Some are questioning the findings of this radiologist, who solely reads x-rays for asbestos lawsuits:

According to the transcript of a deposition in 2004 , Dr. Harron graduated from New York Medical College in 1957, completed an internship at the United States Marine Hospital in New York in 1958, was a radiology resident in New Orleans and then moved to West Virginia in 1961, where he practiced as a radiologist for more than 30 years.

Beginning in the mid-1990's, he stopped treating patients and began reading X-rays and identifying possible cases of dust-related diseases. In 1994 his medical reports supported fewer than 2,000 claims to one of the oldest trusts set up to compensate asbestos victims, the Manville trust. In the next year that number grew to more than 6,000; he averaged about 6,400 reports each year thereafter.

"The dog died and the kids left home," Dr. Harron said in the 2004 deposition. "My responsibilities were over, so I kind of gave up real medical work."

He devoted himself nearly full-time to reading X-ray films. Sometimes, Dr. Harron said, he would conduct a physical examination. Usually he also received a medical history, completed by an employee of a screening company, that would include a statement that the person was exposed to asbestos. Dr. Harron said he relied mostly on the X-ray review, not on the history.

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over my med body! hosts Grand Rounds this week. Come get the weekly best of the medical blogosphere.

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Fat buttocks require longer needles: They needed a study for this? "Fatter rear ends are causing many drug injections to miss their mark, requiring longer needles to reach buttock muscle, researchers said on Monday.

Standard-sized needles failed to reach the buttock muscle in 23 out of 25 women whose rears were examined after what was supposed to be an intramuscular injection of a drug.

Two-thirds of the 50 patients in the study did not receive the full dosage of the drug, which instead lodged in the fat tissue of their buttocks, researchers from The Adelaide and Meath Hospital in Dublin said in a presentation to the annual meeting of the Radiological Society of North America."

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retired doc wonders about FPs giving CME drug talks. "So why are they chosen to speak about certain topics to a group that typically consists of FPs, NPs and internists? Maybe they believe that if primary care docs listen to another primary care doctor who is apparently very comfortable in managing bipolar patients,they will have fewer qualms in prescribing the latest atypical antipsychotic medication for the next bipolar patient. Is the message crafted to be 'we, primary care doctors, do not need to refer bipolar and BPH patients to the psychiatrists and urologists, we will just prescibe drug x and drug y'"?

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"Shy pee". "Some four million people in the UK are unable to urinate in public toilets because of a social phobia commonly called "shy pee", it is claimed.

Experts have called on the medical profession to be more aware of the condition as sufferers can wait decades before seeking treatment."

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10 percent of children ages 2 to 5 have "obvious" psychiatric illness.

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A little bit of research can be far more dangerous when taken out of context. "Research is complicated and, often, in boiling it down to a few easily digested sound bites, the full complexity and meaning of the information is lost in the media. It is worth remembering that
sometimes a little bit of knowledge can be far more dangerous than the
very crisis it concerns."

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Nominations are underway for the 2005 Medical Weblog Awards. "Welcome to the second annual Medical Weblog Awards! These awards are designed to honor the very best in the medical blogosphere, as decided by you--the readers of these fine medical blogs.

It's been another year filled with explosive growth, stirring debate, and excellent writing -- in a number of fields. Our categories reflect this diversity. The categories for this year's awards will be:

-- Best Medical Weblog
-- Best New Medical Weblog (established in 2005)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog"

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The online Medicare help site sounds good, until you realize that only 20 to 30 percent of all seniors go online.

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Cheerleaders make good drug reps. "Known for their athleticism, postage-stamp skirts and persuasive enthusiasm, cheerleaders have many qualities the drug industry looks for in its sales force. Some keep their pompoms active, like Onya, a sculptured former college cheerleader. On Sundays she works the sidelines for the Washington Redskins. But weekdays find her urging gynecologists to prescribe a treatment for vaginal yeast infection." (via DB's Medical Rants)

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Merck will cut 7,000 jobs. Note to the Texas Vioxx jury: Consider the message sent.

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The exodus of nurses and doctors from the Philippines has left the country's own health system in a state of near collapse. For no charge, I will offer my solution - pay higher salaries:

But above all, the study found, salaries were a major factor, averaging $3,000 to $4,000 a month, compared with $180 to $220 a month in the Philippines.

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More on the rising C-section rates. "Locally, doctors say C-sections are definitely more prevalent than they were several decades ago, and they agree that malpractice lawsuits and concerns about vaginal births after Caesarean sections are major reasons why. But they downplayed mothers' desire to schedule births as much of a factor."

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"Why should I care about how much my doctor has to spend for insurance? Doctors make WAY more than I do, so can't they afford it?" "In Chester County, PA, there isn't a single fulltime neurosurgeon on staff at any of the county's five hospitals, which serve 450,000 residents. There used to be six fulltime neurosurgeons in the county - before rising premiums drove them to other positions and other states. The last fulltime neurosurgeon to leave would have been forced to pay $283,000 for a single year's coverage.

That neurosurgeon's departure forced the closing of the county's only certified trauma center at Brandywine Hospital - so now, patients who require immediate neurosurgical intervention must be transported elsewhere. While a helicopter can generally get a patient from Point A to Point B within the 'golden hour' of optimal care, sometimes weather makes flying impossible. So far, we've heard reports about six patients who've tragically died because a neurosurgeon wasn't immediately available at a Chester County hospital.

It's not that the hospitals in Chester County haven't TRIED to recruit neurosurgeons - they've been trying for years. It's that medical liability premiums in PA are so high in comparison to other states and that the possibility of being sued is so certain that no one (in his or her right mind) wants to practice there."

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Good for business: "Ms. Bennett has had the nerve to apply for a job seven miles from home, to avoid what can be a four- hour commute to work in Washington should there be rain or rubbernecking. She wants to be close if her kids get sick, or even to have lunch with them sometimes. She gamely shared her story with me about how she wants a new job--and not in a crazy place where she is expected to work late every night. She wants to 'see the sun go down from home.' She is willing to take a demotion and therefore a cut in pay. She thinks it will reduce her blood pressure and headaches.

And I'm thinking, 'I'll never see her again in the office, and then how will I pay my mortgage, my car loan, my cleaning lady, my kids' college tuition, etc., etc.?'

Why does she think she should be different from all the other patients who get up at 4 a.m. and come home at 6 p.m. in a condition best-likened to a wet rag? No energy to cook, just give the kids pizza for supper and throw them into bed. Clean up, do the laundry, fall into bed for an all-too-short night of restless sleep, then stumble out the next day to do it all again--flogged along by caffeine.

These are the people who seem to make up a large part of my practice--and who look at me as if I'm crazy when I tell them they need to make time to exercise, or to brown bag it for lunch instead of nipping over to Arby's for a roast beef sandwich and curly fries.

These are the kind of people who are my bread and butter--excuse me, bread and 'I can't believe it's not butter.' I don't want them to exercise or eat healthy. When it comes to the bottom line, where's the incentive for a doctor to get his patients better at all?"

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Kidney swap: "They were strangers who shared a dire dilemma: two women whose husbands each needed a kidney but who could not give one of their own to their spouse.

After being brought together by a hospital and arranging a swap in which each woman donated a kidney to the other's husband, they planned to share Thanksgiving dinner on Thursday to celebrate the arrangement that saved two lives and bonded four new friends."

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"Fat people continue to be perceived as greedy and indolent pariahs, who refuse to exercise any self-control over their eating habits." Commentary on the NHS' decision to restrict surgery to obese patients.

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Intervening "pre-code": "Howell hopes the team will prevent delays like one he described to the Beth Israel Deaconess board of directors last month: Doctors admitted an elderly man to the hospital for gastric bleeding. When his systolic blood pressure dipped into the 80s, his nurse and an intern gave him intravenous fluids to push it back up to normal range. His pressure climbed back into normal range. Over the next eight hours, the patient's blood pressure kept falling, and they kept pumping in fluids. Low blood pressure is generally not life threatening until it dips into the 70s or 60s. But they failed to recognize that the subtler decline masked a more serious underlying problem: massive stomach bleeding. The next morning, a senior doctor did, and transferred the patient to the ICU, which has the staffing expertise and equipment to intervene more rapidly. But it was too late . . .

. . . Now, when a patient's condition worsens in one of six specific ways, including systolic blood pressure that dips below 90, or when a nurse has marked concern about a patient, the nurse is required to set into motion a series of events called a trigger. The nurse pages a special team -- including a senior nurse, an intern (a first-year doctor), and a respiratory therapist if it's a breathing problem -- immediately to the patient's bedside. The intern is required to notify the resident, who is required to call the attending doctor, or senior physician."

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The toothache: A common ER scenario - a tragic outcome. "For more than a week, his family says Larry bounced between his dentist and the emergency room.

'There was a conflict between whether it was a dental issue or a medical issue,' said Larry.

Larry says his brother eventually checked into Shands where an abscessed tooth was removed. The family thought it was over but by week's end, they knew something was wrong . . .

. . . His brother went down hill fast. The family thought he would get better, but doctors told them it was too late. Terry was checked into hospice where he continued to spiral. Late Thursday, November 6, just days after feeling the first pain, terry Trombley was dead.

According to his death certificate, a brain abscess was the cause."

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Some doctors worry that the growing availability of PPIs will mask some signs of esophageal cancer.

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"Sheep have more rights" than TennCare enrollees. "Bridges' case shows why the TennCare cuts are so unfair and so outside the values of Tennessee. She has lived a contributing life. She raised her kids and now they are contributing. She represents Tennesseans who are paying taxes, and our government says "no" to them in their time of need. And like thousands of Tennesseans, she has had to be battered by a faceless accuser in an atmosphere of intimidation where security guards are present if you fight too hard for your survival."

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New Orleans health care is still in dire straits. "At the emergency room at Oschner Clinic Foundation in neighboring Jefferson Parish, visits are up 35 percent over this time a year ago, the number of uninsured patients has tripled and some wait as long as 10 hours for care, emergency chief Joseph Guarisco said.

But for most of the 25,000 clean-up workers -- many of them uninsured -- and an estimated 75,000 residents, health care is delivered in military tents that recently moved from a parking lot to the concrete floor of the convention center.

"Now my fear is the entire country will think it's appropriate to care for our patients in a tent," said Peter DeBlieux, director of resident training at Charity. 'I don't think the rest of the country appreciates we are seeing people in a tent.'" (via Health Business Blog)

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A lot of times they have no choice: "Three Los Angeles hospitals regularly put discharged patients with nowhere to go into taxicabs bound for skid row, hospital officials acknowledged this week.

Officials at Hollywood Presbyterian Medical Center, Kaiser Permanente West Los Angeles and Martin Luther King Jr./Drew Medical Center said the practice is necessary because skid row is the only place in Southern California with a concentration of social services for the patients, including homeless shelters and drug and alcohol programs." (via The Health Care Blog)

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A reader asks me to comment on the hockey player who suffered a seizure. Dr. Centor has already written an excellent analysis of this.

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A teenager with a peanut allergy has died after kissing her boyfriend who had eaten a peanut butter sandwich hours earlier.

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From alcoholic to Physician of the Year.

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The sleep drug market is about to get a whole lot bigger. "The $2.5 billion U.S. insomnia market is expected to get a whole lot bigger starting in the second half of next year . . .

. . . A massive ad campaign - one analysts compare in magnitude to those for Viagra and Lipitor - is expected to follow six months after the initial rollout of Indiplon."

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A lump in the breast: Biopsy everything.

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Private MRI clinics in Canada are luring away techs from the public system. Money talks.

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The malpractice case of a decapitated baby during delivery has been settled. (via a reader tip)

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Is the grass greener on the other side? "Most Britons are in denial. They still expect the NHS to act like a white-capped, blue-smocked nurse, all comforting assurances — “there, there, we’re here to take care of you” — with not so much as a hint of the harsh truths of limited services requiring a list of priorities and tough accountancy. The notion that in fact our health system has been prioritising since its inception (what is an A & E department if not an example of urgent prioritising?) and that rationing has been an unspoken but continuous undercurrent in the treatments it can offer (think of the hip and knee operations that Ipswich Primary Care Trust wanted to deny the obese) proves, for many, too bitter a pill to swallow.

The American health system, with good reason, has often received a bad press. The joke is that as the ambulance stretchers come to carry you from the scene of the accident their first question is: 'What’s your insurance policy number?' This sounds cruel and hard-hearted, but at least Americans, who prize their health and wellbeing even more highly than Britons do, believe in putting their money where their mouth is." (via a reader tip by JCaffey)

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End the "lawsuit lottery". "By Tennessee law, up to one-third of the award goes to the plaintiff's attorney. Television in the Memphis area is rife with ads from various firms. One firm asks people to contact them for 'any injury, major or minor.' Another states 'the sky's the limit.' The result has been both a proliferation of lawsuits and a sharp rise in the money paid out by SVMIC through both settlements and jury awards.

In 1991, there were 877 new suits filed against policyholders of SVMIC, but in 2004 there were 1,534. That's a 75 percent increase in claims filed."

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Harnessing the power of idle home computers to fight AIDS. "The effort uses home computers to test thousands of chemical compounds against variations of a protein found in the HIV virus, one combination at a time, said Arthur Olson, a molecular biology professor at the private Scripps Research Institute in La Jolla, California.

The project will seek the compounds that prevent the most variations of the virus from reproducing, Olson said. The most promising will undergo laboratory testing.

Researchers will look at compounds whose effects resemble those of protease inhibitors, drugs that have allowed many people infected with HIV to keep the disease from becoming full-blown AIDS."

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Wall Street is preparing contingency plans for a possible bird flu pandemic"If it's a coffee shop, you close down and just shutter it and absorb the losses. But when you are talking about a worldwide
financial network, the premium, the reward, will go to the companies
who figure out how to participate in that network even if a point is
significantly impacted."

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Now, that's really cheap - UK hospitals are closing call rooms. "I don't understand it. They cannot cost a great deal to keep open, yet can make such a difference."

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The third Vioxx trial is coming up. "Irvin's health will be a factor. His widow says he was in very good health when he began taking Vioxx, but Merck notes that he received a Vioxx prescription from his son-in-law, an emergency-room physician, without a checkup.

Also, Irvin's autopsy indicated he had clogged arteries, and a clot in a major coronary artery caused an irregular heartbeat and death. Merck and Plunkett disagree on whether Vioxx was a factor in the clot formation."

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Thanksgiving in New Hampshire

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Happy Thanksgiving!

A warm "thank-you" to everyone who reads and supports this blog.

No blogging today - feel free to catch up with the other excellent medical blogs.

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Patients see it too.



(via Medical Economics)

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Proud of it.



(via This Makes Me Sick)

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The disadvantage of being a computer-illiterate physician. "I’ve now seen two really excellent physicians really stumble when it comes to using an electronic medical record, and it puts them at a severe disadvantage. While they could easily perform a better and faster physical than me, take a better history, and come up with a better list of possible diagnoses, I’ve got them beat hands-down when it comes to entering orders, medications, consults, or clinic notes. They hunt and peck with two fingers, staring at the keyboard, and click everywhere very cautiously. They’ve learned one way to get the system to do what they want it to do, and while it works, it makes a lot of wasted time. One of the physicians even told me he has to come in on weekends to get all his notes written, because it takes him so long."

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A doctor needing a kidney transplant talks about internet donor matching sites. "The Web site is vital for people like me. But it has also provoked criticism. One surgeon, Dr. Douglas W. Hanto, head of the ethics committee at the American Society of Transplant Surgeons, has said such brokered transplants would 'undermine trust in the whole system.'

Last year, Dr. Hanto's group asked its members to boycott privately arranged transplants. To me, this seems utter nonsense. The 'system' to which Dr. Hanto refers is the united network sharing list. It is for dead donors. The Web site is for living donation.

Not only are these different pools of donors, but a live donation also takes the recipient out of the cadaver-waiting pool and thus, in my view, actually benefits people on the list because they can move up." (via a reader tip)

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Obese patients in the UK are denied operations. "Three Suffolk primary care trusts have ruled patients with a body mass index (BMI) over 30 will not get operations like hip and knee replacements."

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A patient faced an agonising three-month wait for the results of a cancer test because a secretary wasn’t available to type a letter.

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Is it worth it? A doctor has her license pulled because she was countersigning prescriptions for patients receiving their medications from Canada. She was paid $1 per signature.

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A doctor tells a patient to sue him and the hospital - the patient obliges. "Carvelot'’s family was told after surgery by Dr. Daily that the hospital's machine was not functioning properly and that he was without oxygen for a period of time and he should see an attorney."

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Hell hath no fury: A woman is being held in jail after biting a man's ear knowing that she was carrying the hepatitis C virus.

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