Friday, June 30, 2006

Why physician salaries matter

Orac explains:
When faced with the prospect of taking anywhere from 4 to 12 years to finish training in a specialty so that they can actually practice, during which time they make a pittance in salary and work ridiculously long hours, even with the 80-hour work-week restrictions, more and more of the best and brightest are deciding it's just not worth it.

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Screening colonoscopies in Canada: What's the point?

Same old single-payer story. Why have screening guidelines at all if it takes so long to get the test?
Quebecers hoping to be screened for colon cancer are facing up to a year-long wait for diagnostic tests that could save their lives.

That's unacceptable, Barry Stein, head of the Colorectal Cancer Association of Canada, said yesterday.

"You can't just walk in the door and get a colonoscopy. Why? Not enough (specialists), not enough equipment," Stein said.

Quebecers aren't alone. Canadians attempting to follow their family doctor's advice to get a colonoscopy at age 50 are having trouble booking a specialist.

But the situation is dire for those at risk. For example, people with a family history of cancer aren't getting tested in a timely manner, experts warned.

Some aren't taking chances and are opting for testing in a private clinic.
(via Health business blog)

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Not all drug addicts fit the stereotype

Case in point.

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The "curse" of having a girl in India

An Indian BBC correspondent writes:
If our baby is a girl - her arrival is likely to be greeted, by some, with condolences. A friend - delighted with his new daughter soon became infuriated at comments that his home had been cursed with a girl.

"Relatives arrived laden with gifts of sweet meats," he said. "They cuddled her and shook their heads at our misfortune."

These are attitudes engrained in many sections of Indian society. More than 10 million female fetuses have been aborted in India in the last two decades.

The prospect of paying a dowry and knowing a daughter could never generate the income of a son is enough for some families to commit murder.

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Insurers are starting to cover the HPV vaccine

They'd better.

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How reimbursement woes hurts patient

Here's a real-life example:
If you pay the front-line doctors they will take on the patients who will then have a place to go when they are sick, which will dis-impact the ERs of the country, encourage doctors to practice in rural areas, help stop disease processes before they get to the stage of needing intervention and decrease the number of hospitalizations.

The entrance into the health care system needs to be the local, personal, patient physician. Let them be the gatekeepers, but make then WANT the job by paying them.

Is there any other business where the owner says: "I charge $1.00″ but they are only paid 3 cents?

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A cure for cancer

At least for cervical cancer. A panel unanimously recommended the HPV vaccine for girls aged 11 and 12.

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The hierarchy of a medical team

Right on the money.

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Thursday, June 29, 2006

ATLA: "There is no healthcare crisis"

The ATLA president talks about malpractice:
The only places where people have trouble finding an OBGYN to do any procedure are in rural, poverty-stricken areas, where the OBGYNs don't want to live and practice. I do a lot of obstetrical negligence cases, and the cases seem to come out of poor areas. You see people getting better healthcare in big, urban centers, for the most part -- although mistakes are made there, too -- and that's where the doctors want to live.

They want to live in nice places with good schools where they can raise their families, and they don't want to live out in the country and they certainly don't want to be the only OBGYN in some rural county, meaning they have to cover all of the deliveries all the time and never get a day off. It's working conditions that make this difference; it's not medical malpractice premiums.
(via This Makes Me Sick)

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Not enough ER docs?

Just throw money at the problem.

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Six "must-have" medical tests for women

I always like to criticize articles on "must-have" medical tests, since they often get it wrong. This one isn't bad. There is a mistake on the bone-density test recommendation:
All women under the age of 65 should have one, but any post-menopausal women with risk factors should have one.
It should be all women over the age of 65 should have one.

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Obese . . .

. . . or giant cyst?
A doctor is facing a charge of professional misconduct after allegedly failing to recognise a patient had a giant abdominal cyst.

A tribunal heard he told her she was overweight and prescribed diet pills.

The 44-year-old mother was eventually taken to hospital in severe pain, where a 14.7kg cyst was discovered and surgically removed.
Update:
Link fixed. Sorry.

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A mother kidnaps her child looking for alternative therapy

The child is in need of a kidney surgery, but the mother wanted to find "other options":
The case of a mother who took her 9-month-old child on the lam, frantically searching for alternative therapies as state and medical authorities demanded kidney surgery for the boy, unfolded before the public last week like a high-drama television show. But at bottom, it pitted the rights of a mother and father against the power of the state.

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shrinkette is leaving us

Sad to see. shrinkette has guest-blogged here several times, and will always be welcome to. She'll be missed.

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The top five medical errors in comic books

Resident comic book expert/MD Scott takes an annotated look. For instance:
3. You Cannot Shock A Flatline When the heart goes into asystole (a term for when it stops beating and has no electrical activity), the treatment is NOT defibrillation. To restart a non-beating heart, the recommended treatments are CPR, epinephrine, atropine, and transcutaneous pacing. Defibrillation does more harm than good.

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Big Pharma vs generics

The strategy appears to be making their own generics, and trying to put little generic pharma out of business.

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The bizarre and savage practice of "breast ironing"

Barbaric:
BBC News on Friday examined the practice of "breast ironing" -- which some mothers do to their daughters in Cameroon in an attempt to prevent sexual advances of boys and men -- and a recently launched campaign to curb the practice. According to BBC News, breast ironing involves "pounding and massaging the developing breasts of young girls," most often with a wooden pestle and sometimes with heated bananas or coconut shells. Statistics show that 26% of girls in Cameroon undergo the practice during puberty, BBC News reports.

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Guess which state has the most expensive health care in the world?

Find out here.

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Why single-payer won't work

From an editorial this past weekend:
A single-payer system would guarantee that health-care services need to be rationed to control costs. Affluent Americans would buy access to health-care services that would be out of reach to lower-income Americans. Reimbursements to providers will decrease because the government is controlling the purse strings, causing fewer physicians to practice and the quality of care to decline. Our tax burden will grow and both employers and employees will have to pick up the tab.

Single-payer advocates like to talk about the supposed low administrative costs of Medicare and how universal coverage will be much more efficient. What they don't tell you is that their figures ignore the administrative costs transferred to the private insurers (such as Highmark, HealthAmerica and UPMC Health Plan) who provide the vast majority of Medicare coverage through managed care products. When this is taken into account, Medicare does not run much more efficiently than any private sector health insurance program.

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A pharmacist wonders about prescribing medication

An insightful piece responding to the Canadian controversy allowing pharmacists to prescribe medication:
That said, I would trust a pharmacist over a PA or an NP when it comes to managing complicated drug therapy. There is no question in my mind about that.

There would also need to be a better way to keep (and share!) medical records with other providers. It would be awesome if everyone could be on the same page, but this hasn’t happened and won’t happen for a while. As we move towards healthcare as a collaboration and discussion, we’ll gradually see this occur as a positive feedback loop wherein one fuels the other. I can’t tell you the number of times I’ve wished that I could see a patient’s medical records when answering the question "Why am I on this medication?" Pharmacists can make educated guesses, but if the medication can be used for a million and one different things, and so long as they are kept mostly in the dark, that’s all they are: educated guesses.

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The teen choking game

Apparently it's more common than you think:
The biggest problem about this game — besides its potential deadliness — is that it's fairly easy to hide. Accurate numbers on how many teens try it are hard to pin down. A New Hampshire medical examiner who handled the cases of two teens who died playing the game told the American Academy of Pediatrics that it "boggles my mind how prevalent it is."

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Wednesday, June 28, 2006

"No matter whether you win or lose, you die a little with every case"

Indeed:
Although 70 percent of malpractice cases are either dropped or dismissed by the plaintiffs, being sued exacts a terrible toll. I won my own case at trial in 2002 after six years of litigation, but not a day goes by that I don't think about what I lost in the process in terms of the weeks spent reviewing, preparing, educating lawyers, being deposed and finally going to trial.

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"Right now, we have a system that rewards disease"

So says a naturalist. He's right. Here's what he prosposes:
What if we had a system where you paid your healer a small monthly fee to help keep you healthy? Under such a system, the healer is financially punished when his or her patients aren't healthy. There's actually a financial incentive for the healer to make sure that everyone stays as healthy as possible. That would be an economic incentive that turns the entire system of healthcare on its head, because right now our current system financially rewards disease.
This system is called capitation. It was tried before and failed miserably.

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Professional breast feeders

They are re-emerging in China:
The case of a poor mother from the Chinese countryside hired to breastfeed an affluent city-dweller's baby has stoked controversy over the ethics of the ancient practice of wet nursing.

Professional wet nurses have appeared in major cities across China, the Beijing News reported on Wednesday, fueled by rising incomes and a demand for healthy milk.

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The NHS advises against beta-blockers for hypertension

I wonder if the JNC will follow suit.

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The Literary Cheese Wheel

Maria hosts this latest effort from the "literary" medbloggers. I particularly enjoyed Dr. Charles' contribution.

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That's gratitude

Look at what Delta Air Lines sent a doctor who rounded on three patients mid-flight.

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Only 55% of death certificates are correct

One reason is that there is little desire to perform autopsies on the elderly, or as Dr. Crippen says, "Do you really want to chop-up granny?"

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Tuesday, June 27, 2006

David Studdert testifies for health courts

Mr. Studdert has received a fair share of bashing on this blog, so I read with great interest his Senate testimony supporting health courts, in conjunction with Common Good.

He addresses the skewed portrayal of his famous study:
Some outlets ran headlines like, "Most malpractice claims are legitimate, study says." Others announced, "Study asserts many medical malpractice suits groundless." The American Medical Association's response began, "Today's study is proof positive that meritless medical liability lawsuits are clogging the courts..." The Association of Trial Lawyers for America (ATLA) declared, "New study shows courts not clogged with frivolous medical malpractice lawsuits."

These reactions are not surprising. The warring parties - —typically the medical profession and their liability insurers versus the plaintiffs'’ bar and various consumer advocacy groups - —are prone to extreme claims about the system's vices and virtues. Often, these claims are little more than partisan rhetoric, unsupported by hard evidence about how the system actually performs. Even when that evidence is at hand, each side tends to spins it to their own advantage.
He counters my argument that the current system is merely a test with a 63 percent specificity:
Do these results represent a passing grade for the system or a failing one? The answer depends partly on one's expectations going in. Those who believe the system should attract only legitimate claims and reject every single illegitimate one will see red flags. But these are unrealistic expectations. Sometimes patients and their attorneys don't understand what has happened. They know a serious and unexpected adverse outcome has occurred, but not why, and litigation may be the only way they can find out.
I don't happen to agree with that, but we'll leave that for another post. He does however, contend that the current system needs to change:
To interpret this pair of findings as indicating that the medical liability system "works," however, would be wrong.
One shortcoming he touches on is defensive medicine:
Defensive medicine refers to changes in the way care is delivered - —the ordering of unnecessary tests, for example, or ceasing to perform high-risk procedures - —which are motivated by fear of litigation, rather than good medical practice. It is not known with any reasonable degree of certainty how prevalent defensive medicine is, what its health impact is, or how much it costs the health care system. But there is solid evidence that it exists, and its adverse impact may be very substantial.
Another is a fundamental philosophical difference between lawyers and doctors:
There is friction between malpractice litigation and the quest to improve the quality and safety of medical care. Trial attorneys believe that the threat of litigation is needed to make doctors accountable, and that it ultimately makes doctors practice more safely (even though most empirical research has not found evidence of such a deterrent effect.) Physicians do not believe the litigation contributes to the quality of care. On the contrary, they argue that the malpractice system threatens quality, both by chilling interest in openness and quality improvement activities and by stimulating the kind of defensive medical practices described above . . .

. . . In the absence of evidence from alternative approaches to compensating medical injury, this is surely an unending and unwinnable debate.
The last point is a major reason why the eternal battle between doctors and lawyers will continue.

Interesting reading. Kudos Mr. Studdert.

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Public support for health courts

Nearly two-thirds of Americans support health courts.

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They're running out of ER docs in Canada

Family physicians are starting to staff ERs.

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The cost of an operation can vary by up to 100% between hospitals

We've got a long way to go before useful price information is available.

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The UK is forcing residents to work abroad

Part of a draconian cost-cutting measure:
Thousands of doctors could face a "career black hole" under a shake-up of NHS training posts, medics say.

About 21,000 junior doctors will be competing for 9,500 training posts in England next year.

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Why you're fat

A look at the top 10 reasons.

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Frist on the ER crisis

It all starts with liability reform:
To begin with, we must fix the broken medical liability system that drives doctors out of emergency room practice, increases costs, and contributes to wait times. Some opportunistic trial lawyers, quite simply, have converted our litigation system into a lottery that damages medical care for almost everyone. We should also build more community health centers to provide free or inexpensive care for the uninsured, roll out privacy protected electronic medical records for everyone who wants them, and work to cover more Americans who currently lack health insurance.

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The UK doesn't want health care in the supermarkets

Here's the controversy:
The British Medical Association conference overwhelmingly opposed moves by the government to take health care into the high street.

Doctors said the sale and promotion of tobacco, alcohol and junk food would undermine the health services on offer.

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Grand rounds is up

Medviews hosts this week. Come get the weekly best of the medical blogosphere.

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Monday, June 26, 2006

After a $28m malpractice award the jury is accused of lying

The defense wants to interview the runaway jury:
Since the trial, Womble has filed a flurry of motions, attacking the verdict in a variety of ways. Some are conventional: He is asking Circuit Judge Debra S. Nelson to order a new trial, alleging, among other things, that Davis gave misleading testimony and that her attorney made an improper closing argument.

He is also asking Nelson to reduce the judgment to $290,000.

But his most dramatic request is to interview jurors.

"It's very rarely granted because I think the court, understandably, doesn't want to interfere or impose upon the province of the jury," said Scott Noecker, one of Davis' attorneys.

Womble alleges that three jurors lied during jury selection: Two failed to disclose that they had been involved in lawsuits; the third told them about one suit but failed to mention at least nine others, according to defense pleadings.

Most of those suits were about unpaid debt.

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Sometimes you can't trust Dr. Google

More on being a cyberchondriac:
The young woman waiting to be examined by Dr. Minerva Santos in her Yorktown office was crying hysterically. "What is it?" Santos asked her. "What's the matter?"

The woman told Santos that she had been up all night, sure that her abdominal pain was pancreatic cancer.

How did she reach that awful conclusion?

A consultation with Dr. Google.

An examination by Dr. Santos revealed the real illness -— constipation.

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Why there is a shortage of PCPs in Canada

The same problem can be said here in the US:
I am convinced a major cause of this sorry situation is the fact that family physicians have been virtually excluded from patient care in teaching hospitals with the result that medical students, interns and residents are seldom exposed to family doctors and are increasingly unaware of their very existence.

Most patients in hospital do not see their own doctors at all, from the day of admission until their discharge.

The students and the interns have consequently lost their contact with the family physicians in the community and are unaware or are ill-informed as to their value and stature.

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The brothel, ex-doctor's office, is struggling

Apparently, they're having staffing issues:
"I think it would be very foolish not to continue at this point because I think the market is there - it's just a matter of meeting the supply and demand. We will just continue towards the dream we had in the beginning because it was a correct dream.

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All the salary and medicine, none of the risk

A commenter sees physician assistants as the way to go:
The way to go is to be a PA (physician's assistant). You get all the cool medical work and none of the responsibility. You make a very nice salary and after the Dr. who you work under pays all the malpractice insurance, you're making just about as much as he is.
(via This Makes Me Sick)

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Bad math - NEJM "corrects" the VIGOR study

Another example of how the NEJM kowtows to the lawyers.

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How nurse practitioners are able to spend 4 hours with patients

In most cases, NPs are salaried and not tied to productivity. Thus, they are free to spend hours per visit. If their compensation structure changes to a productivity model, the rushed visits will start to increase.

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Pay-for-performance can save Medicare one billion dollars

We'll find out soon enough if this is the case.

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Is there a downside to 5-star hospitals?

Some say it widens the disparity between the haves and have-nots:
As some of the Washington area's hospitals expand at record levels and add amenities, others don't have that luxury. They are buckling under the burden of caring for the uninsured, raising concerns about widening disparities in health-care facilities.

In Prince George's, more than half of the residents with health insurance go outside the county for care, many to Montgomery, said County Council member Thomas R. Hendershot (D-New Carrollton). As a result, Prince George's Hospital Center treats an unusually high number of uninsured patients, which has forced the state and local government to spend millions to keep it afloat.

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Sunday, June 25, 2006

Analogies and plain english

The Cheerful Oncologist translates oncology jargon for patients.

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Saturday, June 24, 2006

Sometimes dead is not dead

As Michelle Au finds out during a night at the SICU.

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The so-called best time to go to the emergency room

Flea says there is no best time to go. If you can choose when you can go to an ER, you don't have an emergency.

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Man with a 10-year erection is awarded $400,000

The case of a malfunctioning penile implant:
Charles "Chick" Lennon, 68, received the steel and plastic implant in 1996, about two years before Viagra went on the market. The Dura-II is designed to allow impotent men to position the penis upward for sex, then lower it.

But Lennon could not position his penis downward. He said he could no longer hug people, ride a bike, swim or wear bathing trunks because of the pain and embarrassment. He has become a recluse and is uncomfortable being around his grandchildren, his lawyer said.

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