Kevin, M.D. - Medical Weblog

Beware who you refer to

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A delayed biopsy triggers a lawsuit

One of Dr. F's patients was a 44-year-old woman who was given a routine mammogram as part of her annual checkup. The results pointed to a "suspicious area in the upper outer quadrant of the left breast." On receiving the report, Dr. F, a family physician, called the patient into the office to discuss her options. When he recommended a breast biopsy, the nervous woman replied that she wanted to think about it and would let him know when she decided. As he watched her leave the office with the issue unresolved, Dr. F wondered whether she would ever return. His abbreviated note in the patient’s chart read: "Discussed with pt. will advise."

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A pharmacist's opinion shouldn't outweigh doctor's orders

If you have moral or ethical objections to the particular drug called for by the physician, keep them to yourself. Your views on birth control pills and abortion, don’t change the fact that it is dangerous and downright deadly for some women to get pregnant. A few states passed laws giving pharmacists a loophole on that, but if you can’t do your job, isn’t it just easier to find a new line of work than change the laws to fit your prima-Dona attitude? Now we have some pharmacists that don’t believe you hurt quite that badly. The fact that they have never experienced enough physical pain in their life to empathize with someone in extreme chronic pain, doesn’t give them the right to deny a patient the dosage that their doctor has deemed adequate to control their pain.

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Dr. Anna Pou: Here comes the lawsuit fallout

The deaths at Uptown's Memorial Medical Center during the stifling, dark hours after Hurricane Katrina have spawned more than the highly publicized arrests of a doctor and two nurses on murder charges. A predictable thicket of civil lawsuits has also sprouted, records show.

Two suits filed at Orleans Parish Civil District Court concern the deaths of five patients at Memorial, some of them on the same acute care ward that is the focus of Attorney General Charles Foti's probe.

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A doctor has second thoughts about concierge medicine

He knew he would have to part with most of his patients. But it proved much harder than he expected. "When you see the patients and talk with them, and you understand their financial situation and how difficult it was for them to afford [the concierge service]. . . . I had this 90-year-old lady who sold stock so she could pay it. I just could not stand it."

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A charity is on the verge of ushering in a medication for black fever

A small charity based in San Francisco has conducted the medical trials needed to prove that the drug is safe and effective. Now it is on the verge of getting final approval from the Indian government. A course of treatment with the drug is expected to cost just $10, and experts say it could virtually eliminate the disease.

If approval is granted as expected this fall, it will be the first time a charity has succeeded in ushering a drug to market.

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On the proposed Medicare redistribution of reimbursement

'Industry and surgeons have to face up to reality: We have been overpaying for procedures - in particular, cardiac procedures,' Durenberger said. 'We have to do something to change it.'

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There is a shortage of sperm donors in the UK

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A doctor's fraud puts a methadone clinic in jeopardy

On July 21, addiction specialist Marc Shinderman was found guilty of 58 crimes connected with his practice of forging another doctor's name and federal registration number on prescriptions for patients of his Westbrook methadone clinic. He now faces a prison sentence, and his clinic, CAP Quality Care Inc., is the subject of a federal civil action.

That threatens the future of his clinic, which currently serves 488 clients and runs a waiting list, and could have a chilling effect on the creation of new clinics in the state, said Kim Johnson, director of the state Office of Substance Abuse.

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"There's nothing sweet about the doughnut hole"

Although the Medicare handbook clearly describes the coverage break, critics say most Medicare recipients, bombarded with advertising from private prescription plans, focused on deductibles and premiums and the drugs included.

"There was a lot of emphasis on signing up seniors. It was a crusade almost," said Stuart Guterman, a Medicare expert with the nonpartisan Commonwealth Fund. He doubts that many companies highlighted the doughnut hole in their marketing push. "That's not a selling point," he said.

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A doctor's accent

Although foreign-born physicians may have excellent medical training and comprehension of English, patients and co-workers can struggle to understand their speech and are often reluctant to call attention to the problem. For example, the numbers 15 and 50 can sound similar in some accents, as can the words "breathing" and "bleeding." This increases the potential for medical errors, Wilner says.

"People are frustrated when they get in this situation," she says. "Others, especially elderly patients, may be intimidated and not want to ask questions."

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Tort reform in Mississippi

Before tort reform, Mississippi was viewed by outsiders as a state with a "jackpot justice" system that featured frivolous lawsuits and outlandish damage awards.

The legislation has removed a huge obstacle for many companies who were leery of moving to Mississippi. Even some insurance companies who fled the state have returned, including Mass Mutual and St. Paul Travelers.

Trial lawyers and tort reform opponents say the legislation helped big business at the expense of the little guy. But the reality is that the reforms lifted Mississippi's business environment and is helping bring new jobs to the state. And that helps everyone.

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There is no such thing as a medical miracle

Over the next few weeks, Trevor did indeed begin to gain consciousness, an improvement that Debbie took as proof of Dreamhealer's powers. "The doctors said that he wouldn't recover, so to me, that's a miracle," Debbie said. "It's a miracle that he's still alive." Yet of course medicine is not an exact science; doctors can only go by the patient's condition at the time of the evaluation, which may change at any moment. Patients may get better or worse for any number of reasons. Doctors' prognoses are often at least partially wrong, so the simple fact that that Trevor defied one doctor's expectations and came out of his coma is hardly a miracle.

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Canada care: A woman miscarries while waiting for hospital bed

Dr. Chris Eagle says health officials "lost the human touch" in dealing with Rose Lundy, 34, who was three months pregnant.

Her husband, Rick Lundy, had pleaded with emergency room staff at Peter Lougheed Hospital to help his wife find privacy.

But he was told there were no beds and she was left to go through the experience in full view of about 40 people.

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The subtle effects of drug-sponsored lunches

The $258 Merck lunch, for example, cost the company only $10.75 a person and fell clearly within industry guidelines allowing modest meals. But it could easily return thousands of dollars for the drug maker in prescriptions for the osteoporosis medication Fosamax and the asthma treatment Singulair, the two drugs discussed during lunch with two Merck representatives.

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CJD guest-blogs on This Makes Me Sick

As to the counter, from reading in the medical blogosphere, I think that many physicians simply don't like adversarial settings. That's true of most of us, even most lawyers, but I think physicians in particular are acutely sensitive to it. Maybe it's the fact that they (like preachers) aren't used to being questioned and very much enjoy being captain of the ship. I know many don't feel that way, but in general polls show the public very much respects and admires them, and juries certainly defer to them. But it's the process of reaching the truth in our justice system that they don't like . . .

. . . But making us the scapegoat doesn't change the fundamental problems with medicine. For malpractice, even given the worst assumptions about it, is a tiny percentage of its ills. The other problems require far more thought and time to fix, and indeed in some ways seem insurmountable. How do you provide for the largest elderly population in US history? A group with accumulated savings unlikely to last as long as they do? What is going to happen when foreign nations don't so easily fund our adventures, and politicians start looking around to cut costs? Who better than doctors, who are already pretty well off, at least as compared to the rest of the population.

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Orac's doses of woo

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Mixed messages on the Studdert study

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Dr. Anna Pou: The arrest warrant

. . . T.M., Nurse Executive and Director of Education for Lifecare Hospitals, advised affiant that on Thursday, September 1, 2005, conditions at Memorial Medical Center had deteriorated. Lifecare patients were located on three floors awaiting evacuation. There were several patients remaining on the seventh floor of Memorial Medical Center. That morning, Dr. Pou came up to the seventh floor and told T.M. that the patients remaining on the seventh floor were probably not going to survive. Dr. Pou told T.M. that "a decision had been made to administer lethal doses" to these patients. T.M. asked Dr. Pou "Lethal doses of what?" T.M. does not recall exactly what Dr. Pou said, but T.M. believes that Dr. Pou replied morphine and ativan. T.M. asked Dr. Pou if she was just talking about Lifecare patients and Dr. Pou responded that was not the case and that they (meaning Lifecare staff) were not involved in this at all. Dr. Pou stated that "there was no telling how far it would go.” Dr. Pou further advised T.M. that nurses were coming from another part of the hospital to assist Dr. Pou. Dr. Pou made it clear that Lifecare had nothing to do with this. T.M. was advised that Dr. Pou and these nurses were taking responsibility for the patients and that Lifecare staff should leave. T.M. told Dr. Pou that it would take a little while to round up all of the Lifecare staff and get them off of the floor. As T.M. was rounding up the Lifecare staff, she saw two people on the floor who she did not know, but assumed them to be the nurses that would assist Dr. Pou. T.M. left the floor at this time with K.J., D.R., and S.H. They went to the second floor and attempted to check on the Lifecare patients remaining on the second floor, but they were advised by three or four Memorial Medical Center staff that they could not enter that area . . .

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Dr. Anna Pou, Hurricane Katrina, and euthanasia

Dr. Anna Pou, an ear, nose and throat specialist, and nurses Lori L. Budo and Cheri Landry were each booked with four counts of second-degree murder.

"We feel they abused their rights as medical professionals," Foti said. "We'’re talking about people that were maybe pretending they were God. They made that decision. We did not take this case lightly." . . .

. . . Foti said some of the Memorial patients had a DNR, or a "Do Not Resuscitate" order, the pact between patient and doctor that no heroic measures be made by medical staff to save the patient'’s life.

But a DNR is not a defense in this case, Foti said.

None of the four patients were receiving either morphine, the powerful painkiller, or Versed, the brand name for the central nervous system depressant called midazolam hydrochloride, as treatment while at Memorial Medical Center, said Foti . . .

. . . Foti had Pou arrested in her home, while she was still dressed in her medical scrubs, despite the fact that she had agreed to turn herself in weeks ago if an arrest warrant were issued, Pou'’s attorney Rick Simmons said.

In the aftermath of the Katrina crisis, Dr Pou told a Louisiana television station some patients were under "do not resuscitate" orders made prior to the hurricane. "In other words ... to allow them to die naturally and not to use any heroic methods to resuscitate them," she said. "We all did everything in our power to give the best treatment we could to the patients in the hospital, to make them comfortable."

The investigation into deaths at the hospital gathered pace in October 2005 when Bryant King, a doctor working there during the hurricane, told CNN he had heard another doctor talk of putting patients "out of their misery". He had seen Dr Pou holding a handful of syringes later that day, he said.

But in a statement at the time Dr Pou's lawyer, Rick Simmons, painted a picture of medical staff working "tirelessly for five days to save and evacuate patients, none of whom were abandoned".

Polimom'’s finding it very hard to condemn the actions of the folks who were in that hospital. Even if these health care professionals did what they'’re accused of, the chaos and despair in the days following the storm were, I believe, impossible to judge from anyone watching from outside.

That said, I'm quite concerned the media coverage of the charges and the public discussion of what happened is going to spill over onto 'regular' end of life care and be full of misrepresentations, half-truths, and gloriously inaccurate and damaging portrayals of end of life symptom management, comfort care, etc. being life- shortening care, and somehow dangerous and ethically suspect.

What struck me the most, at the time I first posted it, was the vehemence of some commenters about how ridiculous this report was. One suspects there will be no humble pie eaten by those who sarcastically castigated me for posting on such obviously fictitious urban legends.

But sometimes the truth can be more frightening than fiction.

"We have people who are volunteering their services and putting their lives on the line. It's going to make it less likely they'll do that in the future," said Dr. Peter deBlieux, an emergency room and intensive care doctor who stayed at Charity Hospital during Katrina.

DeBoisblanc said it's also likely to make doctors less eager to return as the city tries to recover from the hurricane.

"If you think that going after physicians and nurses while hardened criminals are ruling this town, if you think that's an image that's going to bring people back, you've got to be kidding yourself," he said, noting the recent rash of violent crime in New Orleans.

Some doctors saw the accusations leveled by Louisiana Atty. Gen. Charles C. Foti Jr. on Tuesday as brash, misguided moves that permanently smeared the reputation of three respected colleagues.

Others were disgusted that suspicion was being heaped on a small cadre of healthcare workers who stayed, at great personal risk, to tend to the sick — and in conditions that most American doctors have experienced only in wartime.

"This is vilifying the heroes," said Dr. Daniel Nuss, who supervises the accused doctor, Anna Pou, at the Louisiana State University Health Sciences Center. "I think it's presumptuous for the attorney general or anyone else to try to assign blame for what happened under such desperate circumstances."

I worked with Dr. Pou for more than four years at the University of Texas Medical Branch in the operating room and she was my doctor when I needed surgery.

She is a compassionate lady and has a wonderful bedside manner. After long hours in the operating room, she was always grateful for our work.

I can only imagine what transpired in the midst of Hurricane Katrina and what she and the other nurses were faced with.

Playing God, nah. She, in my opinion, was a patient advocate who helped these do-not-resuscitate patients through a cruel, miserable death that awaited them.

Dr. Steven Miles, a professor of medicine at the University of Minnesota’s bioethics center, told the Associated Press that rather than trying to kill, it is more likely that the three women were trying to relieve patients’ pain "in a resource-poor environment and were doing the best they could."

Miles told the AP that there are cases on record where patients have required apparently fatal morphine doses to relieve extreme pain; he doubts the charges will be proven. "I’m inclined to believe this was palliative sedation that’s been misread," he said. Mercy killings would be "not only highly frowned upon, but also rare. It’s highly unlikely that’s what happened here."

Dr. Anna Pou was abandoned to a medical hell on earth. I wonder where the Louisiana Attorney General was during that time? Some air-conditioned command center?

There's little doubt that Anna Pou will be talking to her Medical Board (and it's a Board that has a reputation for being harsh to the ladies). She cannot practice while charges are pending. No money will be coming in to pay for her defense, or fend off the sharks in the water.

Meanwhile, the general public remains completely in the dark about what is really going down in medicine. After all, it happens in the dark.

And who cares about one "rich" doctor?

In short, Dr. Pou is no murderer. This prosecution has all the earmarks of yet another lynch mob that is more interested in myths than reality, so watch it closely.

I trained under Dr. Anna Pou when she was a teaching professor at the University of Texas Medical Branch in Galveston, TX. I can attest to Dr. Pou’s dedication to her patients, concern for the poor and indigent, and devotion to her profession. She is not only a very skilled Head and Neck Surgeon/Oncologist, but also a person who has a desire to help mankind.

It does not surprise me that she altruistically volunteered to help during the devastating Katrina catastrophe. It is difficult for me to imagine the events that took place- no electricity, limited resources, flooding, mayhem, looting, and gunshots on the streets with critically ill patients to take care of. It is easy for us bystanders to judge the events that transpired. The facts are that us others fled (FEMA, government officials including the mayor, New Orleans Police, and other medical professionals); Dr. Pou and those brave nurses stayed and were tested like none of us have been before. I don’t know if political or entertainment value are the factors that brought these brave soldiers to trial. Be it what it may, I’m sure Dr. Pou and the nurses will be found to be one of the great heroes of this extremely tragic tale. I would hope we the people would bring the federal, state, and local government to trial for placing us on trial.

Chaos reigned supreme in New Orleans. And, help was nowhere to be found. This was not business as usual on the ICU unit. It was hell on earth. It was the equivalent of conditions in a war zone. And, absent absolute depraved indifference to human life, medical judgments made under those conditions should not be second guessed. And, those making the decisions certainly should not be prosecuted for murder and facing a life sentence.

It's disgraceful--as disgraceful as our government's response, or lack thereof, to Katrina.

It's hard to figure out what's going on with Foti in this case. As Criminal Sheriff, he's never been directly involved in pro-life issues, so his opinions on these haven't been all that visible. There's more to this than meets the eye, to be sure, but it's so difficult to see what. The religious forces in the state will want to characterize any euthanasia case as homicide to shut down any legitimization of the concept. Then there's the business of health care. Memorial's pending sale to Ochsner Healthcare might be moving management to throw the doc and these two nurses under a bus.

It's disappointing to read an article such as this, because it indicates how little the truth can have to do with a criminal case in our judicial system.

In contrast, Foti's arrest of Pou and the two nurses is abnormal and ethically flawed. Foti announced his office had filed charges of second degree murder, but he was mistaken. As in Texas, the Louisiana attorney general has no authority to bring criminal charges. That's the job of the district attorney.

"Foti accomplished nothing," said Timothy Meche, a New Orleans defense attorney. "In order to bring criminal charges, the district attorney has to present the case to a grand jury, which most people here think won't indict."

Actually, Foti's theater, factual errors and legal overreaching have done a lot. They slashed the reputations of three caregivers who, up to now, have been distinguished only by their outstanding dedication.

Long after their case concludes, the memory of Foti's witch hunt will linger. Across the country, caregivers are watching. Could they, too, be so casually accused and smeared for giving aid during disaster? Maybe, some of these doctors will conclude, compassion and duty are not worth the risk.

I wonder what the families of the dead people think of this. And I want to know when the people who were really responsible for those deaths will be charged.

Murder charges could bring sentences of life in prison, but dangers also include difficulty with careers and civil suits. "The amount of volunteers is going to be drastically reduced if there is another hurricane because they are not going to take the chance," medical equipment salesman Ray Landry said, citing chats with doctors.

Louisiana State University, where Pou is an associate professor and which has a major medical complex, has fielded many similar complaints, spokesman Charles Zewe said. "We hadn't expected the doctors and nurses to say, 'Next time around, we may not be there,"' he said.

I am surprised that the attorney general would rely on post-mortem drug levels to determine whether these drugs were administered in proper dosages. The drug levels in the patients - whatever they may be - mean nothing. Some patients receive very, very high doses of the medications with minimal effects, while other patients are very sensitive and require very little. The idea that you can check a drug level and determine intent is absurd.

We don't know the whole story from all participants, including Dr. Pou and the nurses: what the conditions were like and what their intentions were. Until all the facts are known, it's wrong for the attorney general to act as if he's dealing with hardened criminals. He may very well be dealing with heroes.

When a diver plunges to the bottom of an ocean full of fish and only comes up with three guppies, it makes one wonder. There were a dozen hospitals operating in New Orleans during Katrina, and 34 people died at Memorial. Dozens more died in other facilities. Out of all those deaths, and all those hospitals, it perplexes that a 10-month investigation could only come up with 1 doctor, 2 nurses, and 4 patients. Were the rumors totally overblown? Or was there a widespread problem, and is what we have just a trio of scapegoats?

It is possible that in all those hospitals with all those doctors and patients only three exhibited suspicious behavior, but it gives pause to anyone with common sense. We are supposed to think that all the rest of those deaths are on the up and up. That there is no moral difference between a patient euthanized and one abandoned. That someone who stayed behind to care for patients for 5 days in 110 degree heat, with no electricity and no drugs besides morphine, is morally indistinguishable from Jeffrey Dahmer. That no one else bears any responsibility for what happened. Just these three villains.

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A former colleague comments on Dr. Anna Pou

I just learned that a former colleague and friend has been charged with second degree murder in the death of four patients at a New Orleans hospital after Katrina. I worked with Dr. Anna Pou in the operating room when we were both in Galveston, Texas for three years in the late nineties. She worked as a head and neck surgeon specializing in cancer surgery and I provided anesthesia for many of her cases. After reading the story my only reaction is that this entire case is about an attorney general making a name for himself. Dr. Pou is a wonderful, caring, highly skilled surgeon. Her concern has always been for the comfort and well-being of her patients.

But where the hell was the Louisiana or New Orleans AG (or for that matter any other level of government) when desperate physicians, nurses and patients needed help? Absolutely effing nowhere. A humane person wouldn’t leave a dog to slowly die or drown in the 105 degree heat, let alone another human. And it seems to me that in absolutely desperate circumstances, Dr Anna Pou did what she felt was best for those patients.Yet six months later a grandstanding DA gets his jollies off by sending physicians and nurses on trial for homicide.

In interviews, several experts said that although they did not know the details of the case, they suspected that it had to be more complicated than the “plain and simple homicide” asserted by the attorney general, Charles C. Foti.

The doctor and nurses may have engaged in mercy killing; if so, given the circumstances, it is not clear that any jury would convict them, a legal expert said. Another possibility, medical experts said, is that the patients were suffering and the only way to keep them comfortable was with high drug doses that may, incidentally, have hastened their deaths. It is not known, though, how much the patients were suffering.

Dr. Pou was known among fellow doctors as a fierce advocate for her patients and a prominent specialist in the difficult field of endocrine surgery. Her father was a doctor, as were two of her uncles, and she was so devoted to medicine that a résumé listing her continuing education courses, scholarly publications and teaching activities stretches for 21 pages.

Another doctor who knows her well, Peter Deblieux, described Dr. Pou as having an excellent reputation in her field. “This isn’t some marginal, flaky physician,” he said . . .

. . . "There are a lot of doctors who have a lot of problems with this," said Dr. Richard Vinroot, who was at Touro Infirmary during the storm. "It’s going to have an impact on a lot of people, because nobody is going to want to stay for a storm again."

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What is the most prestigious career?

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Comment moderation

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Hope for the impending Medicare cuts?

Under the system, payments to doctors would have to be cut by 5 percent a year through 2016 to meet program spending targets, according to federal estimates.

That is unlikely to happen. Lawmakers fear that any reduction in payments could add to the record increases in Medicare premiums and drive doctors from the program.

Rep. Michael Ferguson, R-N.J., said the mandated cuts system is "fatally flawed and it's time we start writing its obituary today."

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Do you take your kids to a pediatrician or FP?

But Wright's situation rests on the fact she's had the same insurance for 13 years.

In the modern U.S. economy, the benefits of having a long-term physician may never accrue anyway. Most people don't stay for decades in one job. Switch jobs and you're likely onto a new plan, with a whole new list of doctors.

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The walk-in clinic boom is betting big on the uninsured

At least six retail clinic chains have emerged in the past few years - all betting there are millions more like Mui, who either don't have insurance, don't have a provider, or don't have the time to spend in a doctor's office for a minor health problem.

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A doctor refuses to give a rape victim the morning after pill

Rebuffed by the doctor, the woman called her gynecologist, who wrote the prescription. Her local pharmacy told her it was out of the drug and referred her to a sister store in Reading.

The former medical director of the hospital said he sees nothing strange about asking a woman from eastern Lebanon County to drive to Reading for a drug.

"People drive to Reading to buy jeans. Even if that were the case, that you had to drive to Reading to get this [prescription], to me that does not rise to a compulsion that you have to pass laws that [doctors] have to do something," Dr. Joe Kearns said.

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Torcetrapib: Pfizer comes to its senses

Previously, Pfizer had said it would sell torcetrapib only in combination with Lipitor, one of several medicines called statins that lower levels of LDL, or bad cholesterol. Cholesterol-reducing medicines are the largest prescription drug category, with worldwide sales of $32 billion last year.

By offering torcetrapib only in a combination pill, Pfizer would have forced patients taking other statins - like Zocor, from Merck -— to switch to Lipitor if they wanted torcetrapib'’s benefits . . .

. . . Now Pfizer says it has changed its strategy. Dr. Joseph Feczko, Pfizer's chief medical officer, said Monday that Pfizer expected to offer torcetrapib as a standalone drug as well as a combination with Lipitor.

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Flea talks about kids and inappropriate ER use

Dr. O'Keeffe took an article on a desperately important topic and trivialized it with a silly list.

Dr. O'Keeffe then compounds the offense by finishing the article with a list of bullet points to consider when choosing a pediatrician. I thought this was an article about inappropriate use of emergency services!

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Is it ever ok to date a patient?

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Is a large settlement sending the right message?

Several years have passed since this case was closed, and I still have trouble sorting out how I feel about it. I'm still surprised by my reaction to the huge settlement given to Mrs. Rios' family. Undoubtedly they suffered a horrible tragedy. But I still don't understand how that equates with their multimillion dollar windfall.

What's even more disturbing, is the message that huge award sends to the family. I fear it tells them that if only they'd taken Mrs. Rios to another hospital her life would have been saved. I think that by allowing them to assign blame for her loss to our hospital and the two OBs, we have frozen them in a state of anger instead of allowing them to realize that this tragedy was an unfortunate, but most likely inevitable outcome.

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How obesity is affecting imaging studies

"In the past 10 years or so, medicine has become so dependent on imaging," Uppot said. "Instead of doing very meticulous clinical examinations, a lot of doctors now rely on CT scans, ultrasounds, etcetera, to tell them what's happening inside the body. What happens when you're too big to fit on a table? Or you can fit on a table but the image is poor quality?"

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A former prison doctor is under fire

"He appeared to think that the majority of patient inmates seeking care were faking, and thus he did very little to examine them or treat them," Hepps said. "As a result of this behavior, Dr. Nuygen was referred to as `Dr. Death' by inmates." . . .

. . . Prisoners complained the doctor, who attended medical school in Vietnam, appeared to have difficulty understanding English. Also, because he suffered from Parkinson's disease, Nuygen occasionally experienced tremors and difficulty with voluntary movements, according to his application for retirement benefits.

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Nurses strike back

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Low reimbursement is forcing doctors to crack down on no-shows

For health-care professionals, the charges are a way to recoup the administrative costs of running a business. After all, they point out, assistants and receptionists need to be paid whether or not a patient shows up. And doctors typically aren't salaried, they're paid only for patients they treat. Some patients understand that. But for them, the fees still are one more health expense to shoulder, atop rising insurance premiums and co-pays.

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Physicians pay off a journal to publish their Pharma-sponsored cardiac screening guidelines

The recommendation carried the seal of approval of an established medical journal: virtually every middle-aged man and woman should be screened routinely for heart disease, using sophisticated and pricey technology to take snapshots of clogged vessels.

Usually, such a seismic shift in medical practice -- it would affect 50 million US adults and easily cost $25 billion or more -- emerges from a government agency or a major professional organization. But the guidelines that appeared earlier this month under the banner of The American Journal of Cardiology reflected the passions of a few dozen researchers.

The story of how the guidelines wound up in that journal illustrates how money and medicine intersect and opens a window into the arcane world of the medical publications that land on doctors' desks and influence the treatment patients receive.

The guidelines appeared in a supplement to the 30,000-circulation journal instead of in its regular pages, meaning that the recommendations, which even the authors concede are not supported by rock-solid evidence, were not subjected to the standard review process.

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1880's medical care

At least a dozen medical experts probed the president'’s wound, often with unsterilized metal instruments or bare hands, as was common at the time.

Sterile technique, developed by the British surgeon Joseph Lister in the mid-1860's, was not yet widely appreciated in the United States, although it was accepted in France, Germany and other parts of Europe. Historians agree that massive infection, which resulted from unsterile practices, contributed to Garfield'’s death . . .

. . . "One man suggested that they turn the president upside down and see if the bullet would just fall out," Dr. Barbian said.

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More junk science

Researchers reviewed 70 randomized controlled trials of alternative treatments and found insufficient scientific evidence to support the effectiveness of any of the commonly used remedies: herbs, mind-body techniques, energy therapies using magnets or electrical nerve stimulation, homeopathy, naturopathy or culturally based non-Western medical treatments.

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Over half believe that unhealthy individuals should pay more for health insurance

According to the poll, 53% of respondents also believe that individuals with unhealthy lifestyles should pay higher deductibles or copayments than those with healthy lifestyles, compared with 30% who oppose the practice. Researchers defined individuals with healthy lifestyles as those who do not smoke and who exercise on a regular basis and control their weight.

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