Kevin, M.D. - Medical Weblog

A patient could expect to be seen on time but is not entitled to this. An expectation not an entitlement. We actually could not think of any more entitlements than the one we came up with. Most of what we discussed seemed to be expectations.

Patients with a displaced sense of entitlement are actually quite annoying. Almost as annoying as doctors who have disdain for patients and don't respect their complaints enough to fully listen to their problems. Almost.

Close to 5000 office visits move across me on the river of medicine I call my practice. Not a day goes by where I either fail to meet someone's expectations or come across an unreasonable SOB with a sense of entitlement that their issue should dominate the entire attention of my office because, for example, they are the CEO or the Whaterthehellitis Corporation. It upsets me to not meet a patient's expectations and it enrages me when the entitled cross the threshold.

Not that the Declaration of Independence represents an authoritative piece of work but there is some good quotable stuff in there. Life, Liberty, and the Pursuit of Happiness.

Pulled out my copy of the DOI and looked intensely for the section of free medications. Not there.

I looked for the section on "no waiting more than 10 minutes in a doctors office". Not there.

I looked for "having the doctor call every family member on their private jet with constant updates about Grandma because we are too busy to get our rich fat butts into the hospital to see her ourselves." I originally thought that was there and then realized I was wrong. Not there.

Life, Liberty and the PURSUIT of happiness. Pursuit. The opportunity to have the freedom to pursue a dream or a goal. Not the entitled attainment of that goal.

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I wondered, as I sat there, if I was witnessing a key problem with our increasingly-costly health care system: Patients with insurance don't have to weigh the actual cost of most procedures against the likelihood of benefit.

This point was part of a recent ABC News documentary by Peter Jennings that aired after his death from cancer. Medical care is one of the few products we purchase without a price tag attached. Patients simply want to know if a procedure is covered. If it is, patients assume more medical care -- and more expensive medical care -- is better care.

But Jennings found that's not always true. A Dartmouth Medical School study suggested more medical care often leads to worse outcomes. And while we all love to blame insurance companies for skyrocketing costs, the real reason we're paying so much more is that we are using so much more care.

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And because of reduced reimbursements, the practice began losing money. "She was running herself down physically and mentally," says Moore. "At the end of this particular day, she just collapsed. She was barely conscious. Her skin was silver-gray. I rushed her to a nearby emergency room, and they revived her."

Vaughan remembers her blood pressure being 70/50 (normal is 120/80). Moore remembers it being lower than that. They both agree that her adrenal system had collapsed, and if she hadn't obtained immediate medical attention, she probably would have died.

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These are the people who can tolerate a bit less discomfort or uncertainty than the average person. These are the patients who cry wolf. The only trouble is, sometimes there really is a wolf. The challenge for the doctor is knowing when.

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Airborne said that a double-blind, placebo-controlled study was conducted with "care and professionalism" by a company specializing in clinical trial management, GNG Pharmaceutical Services.

GNG is actually a two-man operation started up just to do the Airborne study. There was no clinic, no scientists and no doctors. The man who ran things said he had lots of clinical trial experience. He added that he had a degree from Indiana University, but the school says he never graduated.

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In an interesting parallel with socialist arguments against school vouchers in America, socialist defenders of "free" health care in Canada warn that allowing private clinics will "drain the public system of doctors and nurses." This is tantamount to an admission that doctors, nurses, and patients are unhappy with the current system, though of course defenders of the status quo don't recognize that is what they are saying. Similarly, Americans who attack vouchers because students will flee the government schools are in fact making a wonderful argument for vouchers: they implicitly admit that when parents are allowed to "vote with their feet," they opt for capitalism over socialism.

Much of what is driving the surreptitious (or at times, openly defiant) move towards a market in health care is the utter failure of the socialist model to deliver services in a timely manner. That is, the surgeries don't run on time. Waiting periods between initial consultation and treatment can run months or even years, causing many Canadians to bolt south to American hospitals to buy privately what they cannot beg from their own government.

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Detractors are fond of saying "“but medical students need to know about these things"” or "“they'’re doing research". Trouble is, much of this so called "education and research" amounts to little more than uncritical promotion of quackery. I'’ve given examples before, and the authors of the MJA piece make the case effectively. They cite data, for example, that of the 175 medical school CAM courses in existence only 4 take a critical approach. This means that the vast majority of curricula promote unproven and implausible methods, implicitly if not directly. Moreover, Medline abstracts overwhelmingly promote, and few if any critique CAM. They also note that the NIH web pages link only to promotional CAM sites as opposed to objective critical sites like Quackwatch.

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"These proposals really do nothing to lower the exposure risk for obstetricians," said Anton-McIntyre, who had confronted Gov. Chris Gregoire last month during a state medical association meeting in Olympia.

Anton-McIntyre, who said she has never been sued for her obstetrical care, told Gregoire that she needed to see improvements in the liability environment or she would give notice to her practice June 1.

"When there is a damaged baby, it is limitless" for damages, Anton-McIntyre said in an interview. "Without some kind of program in Washington to protect obstetricians, it’s unreasonable to expect us to expose ourselves like this."

Anton-McIntyre said she would favor a system more like Canada’s, where the government assumes the costs of caring for children damaged by birth injuries, she said. Similar "no fault" programs funded by doctor fees also care for birth-injured children in Virginia and Florida.

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Nobody wants to cross Dr. Mayda Melendez.

It's not that her patients in the Tiny Steps prenatal program at St. Francis Hospital fear her, they just know they'll never hear the end of it.

If they don't show up for their appointments, a nurse will call and ask why. If Melendez suggests they cut back on sweets and they don't, she will follow up at their next visit, offering more warnings. And they know they can't take their newborn home from the hospital until the baby's first doctor appointment is scheduled -- to see Melendez, of course.

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The parents of 3-year-old boy have sued a prominent pediatrician at the Cleveland Clinic who accused the couple of faking their son's illnesses.

Scott and Tricia Beam of suburban Chippewa Lake were outraged when their son, Tyler, was placed with a foster family while the couple was under investigation by the Medina County Department of Job and Family Services.

The agency based its investigation on a 19-page letter from Dr. Johanna Goldfarb, who had never examined Tyler or met his parents but diagnosed the toddler as a victim of Munchausen syndrome by proxy, a psychological disorder in which parents fake a child's illness or deliberately harm the child to draw attention to themselves.

A juvenile court eventually ruled in favor of the Beams, returning Tyler to their care.

But the couple filed a lawsuit in Cuyahoga County Common Pleas Court seeking damages. They say Goldfarb and the Cleveland Clinic should pay for the parents' mental anguish, embarrassment and damage to their reputations. Both are teachers in the Cleveland school system.

Defense lawyers labeled the lawsuit frivolous. But last month a judge denied their request to dismiss the case.

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Raucous Mardi Gras crowds pose a challenge to emergency medical services every year. But the city this year is bracing itself because emergency rooms are already filled near capacity trying to provide everyday health care for city residents while several hospitals remain closed.

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A few years ago, when our daughters were 13-ish, I was sitting in the field hockey bleachers with a friend. She confessed that she'd just had an unsettling experience at the pediatrician's office.

Seems that in the course of a routine physical, the doctor had shooed my pal out of the examining room, saying it was time for a "private" conversation with her daughter.

He brought in a nurse, and the two of them spent some time talking to the girl behind closed doors.

Afterward , the girl told her mother that the doctor had wanted to know whether she was sexually active.

My friend was livid. She thought she'd been blindsided by a doctor who, at the very least, should have warned her that he wanted to have a little sex chat with her child.

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A pediatrician who asks a child's parent about firearms in their home could lose his or her license or be disciplined under legislation being considered by a Senate committee today.

The bill would prohibit health care professionals from asking a patient about gun possession, ownership or storage unless the patient is being treated for an injury related to guns or asks for safety counseling about them.

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The Health Department has ordered the hospital to stop doing hip and knee surgeries until the next fiscal year, which begins in April, according to Dr. Ethan Lichtblau.

The hospital in the Rosemont district has hit a government-set target number, and depleted its prosthesis budget for this year.

"The government has actually stopped our hospital for the six weeks from doing any more total knee or total hip replacements even though we've been very efficient," Lichtblau said Friday. "They've done it because we've gone over our target, which was an arbitrary target."

The hospital has been focused on reducing waiting times for surgery, Lichtblau said.

Now, the government order will force some patients to wait unnecessarily, the surgeon laments.

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The Bush administration has proposed no increase in the office's budget of $28 million for 2007, even though the number of generic drug applications more than doubled in the past five years, to 777 last year from 320 in 2001.

The agency now has a backlog of 850 applications for generic drugs, more than twice that of 2002.

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A survey of successful former smokers suggests that anti-tobacco spots on TV were instrumental in helping them break the habit.

That finding was reported in the American Journal of Preventive Medicine. The former smokers, all from Massachusetts, said that TV ads were a significant help as they struggled to stay smoke free for more than six months.

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The U.S. Food and Drug Administration says pharmaceutical companies have not tested drugs on pregnant women for ethical reasons, and especially because they're afraid of being sued if the fetus is harmed.

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But we still could be doing a lot better. Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.

There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.

"You get what you pay for," Mark B. McClellan, who runs Medicare and Medicaid, told me. "And we ought to be paying for better quality."

Although the Times article suggests that pay for performance and penalties for errors might solve the "crisis" the data suggest otherwise. Studies on Pay for Performance to date have failed to demonstrate improved quality. A spate of articles analyzing medical error indicates that promotion of a culture of blame by penalizing doctors for honest mistakes is counter productive.

The JAMA perspective is more nuanced: "However, it remains unclear to what extent clinically missed diagnoses represent errors per se, rather than acceptable limits of antemortem diagnosis in the face of atypical clinical presentations. In fact, because the vast majority of autopsy studies come from teaching hospitals, published autopsy series may be enriched for atypical cases."

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Backers of the ban say the formula gifts discourage new mothers from breast-feeding. Formula manufacturers call the ban unnecessary and doubt ending the decades-old custom would lead to a rise in the number of mothers who breast-feed.

Romney, who is weighing a bid for the White House in 2008, said mothers know what's best for their babies, not lawmakers, and women can decide whether to use the gifts.

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The letters come two months after the editors of The New England Journal of Medicine published their first "expression of concern" about the November 2000 article, sharply criticizing Merck — and, implicitly, the outside scientists who were co-authors — for failing to present a complete picture of Vioxx's heart risks.

In their letter yesterday, the outside scientists strongly disagreed. They said that the journal's concerns were misguided and that the article in 2000 had adequately disclosed Vioxx's risks. "Our original article followed appropriate clinical trial principles and does not require a correction," the scientists wrote.

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Two hot-selling supplements used by millions of Americans, including President Bush, are of little help to most people with mild arthritis, concludes a large government study that is part of an effort to scrutinize unregulated health remedies.

For most arthritis patients with aching knees, the two supplements sold in health food stores -- glucosamine and chondroitin sulfate -- were shown to be no better than dummy pills. People who had more acute knee pain seemed to experience some benefit.

Because of that hint of possible relief and other factors, the study may not settle the debate about these treatments even though it is considered the largest and most scientific test to date.

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Wells, a retired pathologist, was first diagnosed with Parkinson's disease in 2000, according to the lawsuit. After taking Mirapex for several months in 2004, Wells "developed an irresistible compulsion to gamble," the lawsuit said.

Wells, who Thomas said had been an occasional gambler, lost several thousand dollars gambling in Las Vegas and on the Internet, according to the lawsuit. After he told his doctor that he thought Mirapex was causing him to gamble, his physician switched him to Requip and increased the dosage, the lawsuit said.

As Wells was losing $14 million — which included about $1.2 million in IOUs called markers that Wells hasn't paid — his wife was unaware of his losses because she wasn't gambling with him, Thomas said.

During the last week of January, Wells' wife began to question him and he confessed to the losses, the lawsuit said. When his doctor took him off Requip, his gambling compulsion stopped, Thomas said.

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It is medicine's eternal quest, these days, to sell impressive science to unimpressed patients, and it is hard to think of a group less equipped to do it than doctors. Doctors are specifically trained not to think like normal people, not to see what others see or to reason as others reason. They - er, we - come to operate in an atmosphere so thin, so heady and attenuated with the power of statistical analysis, that one might wonder whether we are really on the same planet as the patients we try to convince of our truths.

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The inspections are being described as 360-degree audits, as they would involve discussions with the doctor under review as well as the doctors` colleagues and his patients.

Inspection teams will include volunteers and medical experts, as well as external examiners.

The team will then submit a report to a performance committee who will decide if the doctor is up to standard.

The new audit system will start this summer but doctors can refuse to take part in the voluntary scheme.

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"I do applaud all sides for coming together to create a compromise solution," Hewitt said in a news release. "But I think it’s important that we don’t lose sight of the fact that we have not solved our medical liability problems. This solution could be summed up as 'mini-mal.' It’s a bit like having your toe worked on when you need bypass surgery.

It’s great to fix your toe, but that’s the easy part. We won’t get to true liability reform until we operate on the heart of the matter."

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But it is also helped by doctors wearing "functionless" and potentially germ-laden clothing. "Ties, in our view, are an unnecessary piece of clothing," said Dr Vivienne Nathanson, the BMA's head of ethics and science.

"We recognise that people touch their ties and wear them for a long time. People have to recognise the potential danger."

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The research, published in the Archives of Otolaryngology -- Head & Neck Surgery, is based on a small sample and focuses exclusively on two specific drugs: a 240-milligram dose of pseudoephedrine hydrochloride (sold over the counter under the brand name Sudafed 24 Hour) and a 10-mg dose of montelukast sodium (prescription brand name Singulair). "When we compared them head-to-head, we found that for treatment of allergic rhinitis, these drugs at these doses were virtually identical," said Dr. Fuad Baroody, associate professor of surgery at the University of Chicago and the study's director. "This came as a genuine surprise."

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A US team found chewing gum seemed to speed up the return of normal bowel function, and therefore help shorten hospital stays.

They believe gum may stimulate the same nerves as eating, promoting the release of hormones that activate the gastrointestinal tract.

The study, by Santa Barbara Cottage Hospital, California, is published in the journal Archives of Surgery.

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My question: Where was our California Medical Board in this whole issue? If they are our guardians of medical practice, shouldn't the Board have made a formal statement about the role of a California physician participating in an execution as currently requested for the two anesthesiologists?

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But these days, any parent with a PC can do a quick Google search to determine the exact degree to which their physicians are treating them like children. Even the most obscure medical studies are easily accessible. Forget Dr. Spock. I can peruse Danish researchers' findings on the connection between bed wetting and the color blue or whether being exposed to Donald Trump in utero makes my daughter more likely to fail the third grade.

Is this sort of home diagnosis a good idea? No. Are Type A parents going to do it anyway? You betcha.

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Dr. Molly Katz, president of the Ohio State Medical Association, said patients share some blame.

"If you know you’ve got a major issue that you’re ready to talk about and know it’s going to take some time, let us know," said Katz, a Cincinnati obstetrician. "Otherwise, we’re behind the rest of the day."

Physicians, she said, aren’t like other professionals who schedule blocks of time and stick to the clock.

"This is a difficult business — this is your health," Katz said. "Some people are going to need a little more time. They speak slower. You have to listen. You have to hear what they have to say."

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