Kevin, M.D. - Medical Weblog: March 2006

An old-timer bemoans the demise of the physical exam, or hyposkillia:

We need teachers who truly comprehend the value of a good medical history, the rewards of a pertinent physical examination, the power of knowing how to think, and the importance of accountability; teachers who first use the stethoscope, not an echocardiogram, to detect valvular heart disease; teachers who first use the ophthalmoscope, not magnetic resonance imaging, to detect intracranial hypertension; teachers who first use their eyes, not a blood gas apparatus, to detect cyanosis; teachers who first use their hands, not computed tomography, to detect splenomegaly; and teachers who always use their brains and their hearts, not a horde of consultants, to manage their patients.

We need teachers who don't order expensive, state-of-the-art studies when cheaper, conventional tests supply the same information; teachers who don't administer a slew of medications in an effort to alleviate every possible ill; teachers who appreciate that doing nothing is, at times, doing a lot; and teachers who realize that many patients get well despite what we do, not because of what we do.

Those days are long over, my friend. Readers of this blog know why this is happening: time pressures in a fee-for-service reimbursement system and defensive, objective-based medicine.

I recently discussed this with someone who is completely unapologetic about the demise of old-school, physical exam-based medicine: "I compare it to this - why travel by horse and buggy when you have a car available? The same goes for today's medicine." (via Notes from Dr. RW)

Update:
retired doc comments.

Update 2:
Dr. RW addresses some of the comments here.

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Extreme Makeover: Home Edition goes disease-hunting for its families:

Based on the ABC e-mail, it appears that victims of hate crimes and violent home invasions and families coping with the loss of a child killed by a drunk driver make for good television. And the show would also absolutely love to feature those battling skin cancer, Lou Gehrig's disease, and muscular dystrophy. Oh, and families with multiple children with Down Syndrome would be ideal, whether the kids are "either adopted or biological," the e-mail notes. And, shooting the moon, the program's "family casting director," Charisse Simonian, would love to locate a kid suffering from Progeria, the rare condition that causes rapid aging in a child.

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Here's a case where OB's were sued for using an FDA category C medication (propranolol) in a pre-natal death. The problem is, many safe medications don't have, and never will have, studies demonstrating pregnancy safety - thus leaving them category C. This lawsuit will further limit the medication choices for pregnant women.

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No one's happy with their pay raises in the UK. Hey, just be thankful you're even getting a raise. It could be much worse.

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Would you trust your physician more if you knew how they were paid?

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A psychiatrist reveals some things that you may not have known about Mozart.

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A patient constantly wonders if she obtained Creutzfeldt-Jakob Disease from surgical equipment. The solution to her daily worry? A lawsuit:

"There are no cases in the medical literature of CJD having been transmitted following the routine measures of surgical instrument sterilization that we employed," said Sauder said.

If any of the patients are infected, it could take years before the symptoms, including rapidly progressing dementia, are detected. There are no tests for the disease.

Price does not yet know if she has the disease, but wonders daily whether she will develop it, Grant said.

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"Anyone who has not taken money from Merck." That is how Mark Lanier defines a "mainstream" cardiologist.

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Nice try - a felon turns himself in hoping to get medical help. But his plan may go awry:

However, his change of heart may be in vain, as law enforcement sources said the case is so old, there may not be any witnesses or evidence left to bring him to trial, meaning it could be dropped.

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The Canadian town of Port Alice does not have a doctor, leading to closure of their ER.

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Gullible - doctors can be so easily manipulated:

Emily, 22, got a prescription for Ritalin during her last year of college. She giggles as she recounts exaggerating her symptoms during 15-minute meetings with a "bottom-of-the-barrel" doctor her school provided. (The drugs can only be prescribed by seeing a doctor in person.)

The doctor become suspicious when she admitted that she wasn't taking Ritalin every day, Emily says. But he didn't press her on it.

Instead, he renewed her prescription, eventually increasing the dosage to 20 milligrams from the original 5.

"I wasn't telling him I was taking it to stay up at night, because I know that's not really the best thing to say," Emily says. "I was just saying, 'I only take it when I really need it because I don't want to be dependent on it.' Every doctor wants to hear that."

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Can it be that the ivory tower realizes that the medicine they practice differs from the real world?

Randomized controlled trials are used to support clinical practice guidelines, but their results may have limited relevance to physicians in the trenches.

(via Medrants)

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Newt Gingrich thinks the Medicare drug plan is going really well.

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Is Reebok trying to poison the children?

Health Canada is warning parents to get rid of a charm bracelet given out free by Reebok with the purchase of children’s shoes because it contains very high lead levels.

The bracelet has been linked to the lead-poisoning death of a four-year-old boy in Minnesota, who swallowed its heart-shaped charm. The charm, imprinted with the word Reebok, was manufactured in China and found to be 99 per cent lead.

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Join the club - insurance companies are destroying the mental health profession:

Mr. Berman said that when he went into private practice in 1990, participating in the provider networks of various health insurance companies, his maximum allowable hourly billing rate was $95, with about half of that paid by the insurance company and the rest by the patient. Today, he said, rates have plummeted to the point that the usual total reimbursement for psychologists is $65 to $75 an hour.

This drop has forced many practitioners to nearly double their client load simply to maintain their income, he said. Not only are lower fees problematic, but there is also the issue of not being paid quickly by managed care companies, and often having to resubmit claims. The time required to complete paperwork is, of course, not billable.

(via World of Psychology)

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Paramedics wants to treat patients in the ER. I wonder what Dr. Crippen has to say about that? Speaking of the good UK doc, Dr. Crippen pleads that you should immunize your children.

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Home diagnostic tests are surging:

"If a test is (positive), then they obviously go in to the doctor to have further evaluation," said Adams, who founded the company 10 years ago. "If everything is fine, then you don't have to waste half a day going to the stupid doctor."

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Today's episode of Doctors Gone Wild:

First, the chief of gynecology at Jewish Hospital barged into her married ex-lover's house, started screaming and hit the man eight times while his wife hid in a bathroom, police say.

Then, she tried to kick her way out of a deputy's cruiser after her arrest.

Warren County Sheriff's deputies charged Dr. Marianna Vardaka with aggravated burglary and resisting arrest in the Saturday incident.

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Mark Lanier attacks a cardiologist in the Merck trial:

Mark Lanier, who used the metaphor of a person being shoved off a cliff in his opening statement to jurors March 6, returned to that theme with his first question.

"If a person's standing at the edge of a cliff, do you think it's OK to go ahead and push him off?" Lanier asked.

"Absolutely, it's not appropriate to push him off," Rayburn replied.

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Jailed for revealing fetal gender in India:

Government officials sent in three pregnant women as decoy patients to find out if the clinic would carry out abortions based on sex selection.

Audio and video evidence showed the doctor telling one woman that tests had revealed that she was carrying a "female foetus and it would be taken care of".

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New Orleans health care is still in shambles:

While emergency care is available, auditors noted that patients at two hospitals waited up to two hours to be unloaded from ambulances. They also found patients being kept and treated in the emergency room because beds weren't available elsewhere.

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Bizarre non-medical story of the week - Man accidentally divorces wife in his sleep:

Under Islamic law, a husband need only say "I divorce you" three times to secure a permanent end to his marriage . . .

. . . But 30-year-old Ansari said he had no intention of leaving his wife of 11 years.

"I have not given talaq. When I uttered talaq three times I had taken medicines to help me sleep," he was quoted as saying in the report.

The religious leaders said that before remarrying, the couple would have to be apart for at least 100 days and that the wife, Sohela, would also have to spend a night with another man and then be divorced by him.

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When is a patient too ill or old for medicine?

Doctors should take into account the patient's life expectancy and whether the drug is likely to provide much benefit in the months or years the patient has remaining.

Not so cut and dry in these litigious times. Let's say you stop BP medications in someone with terminal cancer. They have a hypertensive stroke. Is the doctor liable?

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On neck ties and white coats . . . should doctors practice naked?

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A bang-on article about superstition amongst the medical staff:

"Every doctor is either a black cloud or a white cloud," said Ponsky, 33, a pediatric surgery fellow at Children's National Medical Center in Washington, D.C. "I am a black cloud. When I'm on call, things are incredibly busy. Crazy things happen."

As unscientific as it sounds, the "cloud theory" is an almost universally known superstition in hospitals, part of a web of widely accepted beliefs and rituals that heavily influence doctors' behavior, conversations and general outlook when they are on call . . .

. . . One physician at NYU Medical Center in New York, for example, believes he cannot perform a routine cardiac procedure without listening to a certain selection of songs in a specific order, according to Michael Postow, a third-year NYU medical student at the hospital. In addition, Postow said, the physician arranges all of the contents of his pockets the exact same way before every procedure.

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10 medical symptoms that require immediate attention.

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Welcome to Kenya, where medical malpractice is barely punished:

Dr Peter Kiama Wangai, a consultant medical doctor, who also happens to be an advocate of the High Court, argues that doctors in Kenya have it easy when it comes to being punished or admonished for crimes and mistakes related to their work.

"I do not remember in the medical-legal history of this country of a doctor who has been successfully sued for his professional negligence and they are many," he says. "I’m a medical-legal consultant and I can tell you confidently, the number of patients I encounter everyday as victims of medical malpractice is overwhelming."

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Not all pathologists are trained to do autopsies:

Autopsies in some rural places often are performed by doctors not fully trained to look for evidence of a crime. In urban areas, they are done by forensic pathologists, who are specially trained and certified as medical investigators.

"If you had a blockage in your arteries going to your heart, about to kill you, would you be comfortable going to a foot doctor?" said attorney John Smietanka, who worked to free the Newaygo County man, Larry Souter, from prison last year.

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Sounds pretty negligent to me:

Nemoto, the ear, nose and throat specialist who was in charge of the boy at the time, was accused of causing Shunzo to die by failing to find out from his mother what happened and neglecting his responsibility take a tomography scan. He sent the boy home without realizing that the chopstick was lodged in his brain.

At least take a proper history and physical.

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A naturopath goes to jail:

The Flanagans said they went to O'Connell after their son's physicians said there was nothing more they could do.

O'Connell told them "he could save Sean and that no Irish kid was going to die on his watch," said David Flanagan, Sean's father.

But Flanagan died two weeks after getting "photoluminescense" treatments in which a small amount of his blood was removed, exposed to light and reinjected along with hydrogen peroxide.

Another patient, Rory Gallegos, 45, developed a severe blood infection after receiving corrosive "Black Salve" treatments that O'Connell said would cause his liver cancer to come out through the skin. Instead, he developed large open sores that wouldn't stop bleeding.

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This is hilarious. (via Dr. Crippen)

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Grand rounds is up. What an incredible edition. Come get the weekly best of the medical blogosphere.

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SI's Peter King talks about not having "home bathroom advantage" for his colonoscopy prep. Mr. King has had three colonoscopies before the age of 50. Recommendations from the USPSTF suggests screening colonoscopies every 10 years assuming a normal result or even small hypertrophic polyps. Unless there's something his doctors are following, I'm not sure why he's having so many.

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Newsweek - "My Black Skin Makes My White Coat Vanish"

I remember talking to one of the white, male attending physicians in my training program after he witnessed one such encounter. "Listen," he said, trying to comfort me, "I can walk in wearing a T shirt and jeans and I'll always be seen as the doctor, even without an introduction. You will not."

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Some law students planning to represent malpractice plaintiffs are unaware about physicians defensive medicine:

Still, several law students say they have learned from the physicians. They now know about the daily pressures and the impacts of litigation on medical practitioners. Until the class, some were unaware that more physicians are practicing defensive medicine to thwart possible claims.

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Distracted by snooker:

Shuna Gregory and Ryan Abrahams's child, Saffron, became critically ill after contracting an infection during birth. She died aged 11 months. Her parents claim that John Miller, a consultant obstetrician, took no action over Miss Gregory's continuous bleeding in the hours before she gave birth to her daughter, in which she suffered a tear in her placenta. The tear caused blood loss, triggering renal complications that infected and eventually killed Saffron.

While Mr Miller should have been paying attention to Miss Gregory's condition, he was instead being distracted by the snooker match on the television in the same room, the High Court sitting in Winchester was told.

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The sad case of a cardiologist closing his practice because of Parkinson's.

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Are lazy employees invoking HIPAA to skirt work?

I'm a general surgeon and I still practice as well as being a medical school administrator, and I have very little problems in general in getting the information I need from other facilities. Of course, there are always people who are looking for a reason not to do their jobs and nowadays they can invoke HIPAA.

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A picture of the LA patient dump (via the Washington Post):

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Imagine trying to navigate Medicare Part D if you don't speak English.

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I couldn't resist. No offense meant - I do value your contrarian input on the comments.

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RangelMD - how cutting physician reimbursement is actually increasing medical costs:

Ironically these Medicare cuts combined with anesthesiologist shortages may lead to increased salaries as hospitals, desperate to find someone to staff surgical procedures, increase subsidies and provide recruitment incentives. Most of this added cost will be passed on to private insurers and some to tax payers as increased medical care costs.

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An interesting malpractice screening panel model in Louisiana:

A malpractice claim must first be filed with the state Medical Review Panel in Baton Rouge. The Louisiana Patients' Compensation Fund appoints an attorney chairman to oversee the process, said James Ryan, the lead attorney in the Patel cases.

Three doctors whose practice areas are the same as the doctor who is the subject of the claim make up the medical review panel. The patient chooses one, the doctor in question chooses another and those two doctors agree on a third, Ryan said.

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Sticks and stones:

A Palm Beach Gardens grandmother, 64, filed suit Wednesday, accusing the retail chain of negligent supervision and intentional infliction of emotional distress for typing in its system in May 2003: "WATCH CONTROLS SHE SEEMS SHADY."

For nearly 20 years, Elizabeth Noah has patronized the Fairway Drive Walgreens near her home in PGA National, she said. So when the retired United Technologies financial analyst picked up a prescription for anxiety medication the evening of Feb. 6, she began to cry when she read the notation on the Drug Utilization Review -- or DUR -- stapled to the bag.

"It hurt my feelings so bad," she said. "I'm always nice. I've been going there forever. I've had secret clearance [at work] and never even had parking tickets. I'm always dressed nicely and have my makeup on and my hair done. I was raised that your reputation goes with you everywhere."

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Michigan is going to make women contemplating abortions the "option" of observing their fetal ultrasounds:

However it is framed, this sort of state nannyism is wrong. Making a doctor fill out one more form that has nothing to do with good medicine is ridiculous. Asking a woman who may be terminating a dangerous pregnancy to look at what she's losing is cruel.

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A Masschusetts hospital withdraws life support on a 12-year old too soon. The recommendation? An ethics committee should review all cases in which a doctor requests to withdraw life support.

A physician should be able to make independent decisions regarding life support. A mandatory, intervening ethics committee is simply hospital CYA.

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Did a plastic surgeon allow felons to conduct physical exams?

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Godfather, M.D.:

In a bizarre incident in Bhagalpur on Friday, goons and musclemen of a local doctor thrashed an income tax team that had come to a private nursing home to do a survey and when the local media-men arrived to cover the incident, even they were beaten up by the doctor's – some of them receiving serious injuries, officials said.

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Mass euthanasia in Japan:

Imizu City Hospital head Hidetsugu Asanoi told a news conference Saturday that the surgeon admitted turning off the respirators after only obtaining consent from the families of the seven patients - three women and four men in their 50s to 90s.

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Ever wonder what sick building syndrome is?

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63% of children in a single Virginia school district are diagnosed as having ADHD, says the USA Today. Some reasons:

This raises suspicions: Are some teachers using ADHD to control unruly students, particularly boys, who are naturally more rambunctious? Are parents seeking an edge for unfocused children who are struggling academically? Are time-pressed doctors handing out prescriptions based on little more than a 15-minute chat and a teacher's note?

How about D - all of the above.

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BiDil isn't doing too well:

NitroMed's only product, BiDil, was introduced with much fanfare last year, after the Food and Drug Administration made it the first drug approved for use by a single racial group.

The American Heart Association officially designated BiDil as a major treatment advance after research indicated it could extend the lives of black heart-failure patients by 43 percent over 18 months. And some financial analysts had predicted annual sales could eventually reach $825 million, based on BiDil's use by about 750,000 black heart failure patients.

But if the first year is any gauge, BiDil does not seem destined to live up to those expectations. The product got off to a slow start after its introduction last July.

That's what you get when you essentially combine two generic medications (a nitrate and hydralazine).

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Young age does not rule out a heart attack.

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Congratulations Dr. Charles.

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A word on comments

As you know, this blog evokes spirited discussion on hot-button medical topics. Many have written about the vitriolic nature of selected comments and asked me to "do something about it". Some thoughts:

1) I believe it goes against the spirit of a blog to moderate or censure comments (except for spam). The anonymous nature the comments gives people the opportunity to "tell it like it is". At the risk of allowing obvious inflammatory and irrelevant comments, much of the debate gives a unique insight "behind the scenes" of medical practice. Some may be offended and shocked at certain comments. I contend that a majority of the comments reflects a level of frustration at our dysfunctional health system that the public may not be aware of.

2) Comments are not visible on the main page. If you are sensitive or easily offended by the discussion, I suggest you do not make the conscious effort to click and read the comments.

3) Unfortunately, I do not have the time to moderate comments.

Thanks for your continued readership and support.

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Arrested for doctor shopping:

A Utah couple went on a shopping spree for prescriptions and now they're facing serious charges. The couple went to a doctor for pain they didn't have.

Joe Christensen: "They were both going to doctors separately and sharing the drugs."

Money-wise, this is the biggest case of prescription drug fraud investigators have seen, but the crime of 'doctor shopping' is happening more and more, and it's costing insurance companies big.

Authorities say Tonya Green shared an illegal pastime with her husband.

Joe Christensen, Dir., Utah Insurance Fraud Division: "They would go to multiple doctors to receive narcotics under the guise that they needed pain medication, and not tell their doctors they were seeing other doctors also."

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More support for a junk-food tax. Discussed here previously.

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Beware of EMLA cream when going to medical spas:

The North Carolina Medical Board filed unprofessional conduct charges Thursday against a doctor who headed a laser hair removal clinic where a student died last year.

Shiri Berg, a 22-year-old North Carolina State University student, died of a Lidocaine overdose Jan. 5, 2005, after she applied a powerful anesthetic gel to her legs in preparation for a laser treatment at Premier Body Laser and Skin Clinic, in Cary.

The medical board alleged that Dr. Samuel Wurster, the former director at Premier Body, acted improperly by authorizing Triangle Pharmacy to blend the prescription-strength gel and then permitting the laser clinic to distribute the gel to patients without a physician taking a medical history or giving a physical examination.

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Instant gratification:

Some 42% of 18 to 29-year-olds told a survey for insurer easyMoney.com they would miss a trip to the doctor as they did not want to wait for appointments.

And some wonder why appointments are so short. There is a cost to being on time.

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The myth of bed-rest efficacy in pregnancy:

Dr. Maloni's investigations reveal that obstetricians in the United States tend to discount both the side effects of bed rest and to believe in its value in the face of evidence to the contrary . . . Dr. Maloni hypothesizes that fear of lawsuits may also play a part in its widespread prescription. Bed rest convinces patients and doctors alike that everything possible is being done to sustain a difficult pregnancy. And it is, after all, cheap to prescribe.

Dr. Tuteur says that patients should not take this advice lying down:

Bilston illustrates one of the biggest problems in the doctor patient relationship. The same patient who insists that she is a consumer of health care, entitled to all information and to control of medical decisions unconsciously views the doctor patient relationship in parent-child terms and acts accordingly. She’s mad at her doctor as if he were her daddy; he gave her the "wrong" advice and she was forced to follow it. Well, the doctor is not her daddy, and she is not a child. If she didn’t believe or didn’t like the doctor’s medical advice, she was free to ignore it or to seek another medical opinion. She didn’t do either, though, because the one thing she surely wanted to avoid was taking responsibility for own medical care.

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A malpractice case from the Massachusetts Medical Law Report:

A 38-year old patient presented to the emergency room with complaints of chest pain and diaphoresis.

He was hyperventilating and complained that his arm was feeling numb. An EKG revealed ST elevations. Cardiac enzymes were within normal limits.

The emergency room doctor administered 1 mg of Ativan. Several minutes later, the patient was found to be unresponsive, cyanotic and foaming at the mouth. CPR was initiated and the patient was defibrillated without success . . .

. . . The expert planned to testify that standards of care required the emergency room physician to have immediately started thrombolytic therapy after the EKG to help abort the myocardial infarction.

The case was settled for over half a million dollars.

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Kevin, M.D. - Medical Weblog

Commentary and opinion on current medical issues by a practicing primary-care physician.

Thursday, March 30, 2006

Wednesday, March 29, 2006

Tuesday, March 28, 2006

Monday, March 27, 2006

Sunday, March 26, 2006

Saturday, March 25, 2006

Friday, March 24, 2006

A word on comments

Thursday, March 23, 2006