Thursday, August 31, 2006

NEJM on primary care

A must-read article on the challenges facing primary care today:
No serious proposals to narrow the income gap between primary care physicians and specialists are on the national agenda. Fee-for-service payment rewards quantity rather than quality, fostering the rushed visits that underlie primary care's shortcomings. Pay-for-performance programs appear to be insufficient to make a substantial difference; physicians could increase their income more -— with less additional work -— by adding one or two patient visits each day than by meeting all the quality standards in current performance-based payment programs.
Medrants waxes eloquent on this topic.

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Hospital CEOs are raking in the bucks

Most of the major non-profit Boston hospital CEOs are making in excess of $1 million.

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Delay in diagnosis suit: Refer early

The jury sends a clear message to a PCP in this case of hematuria which turned out to be bladder cancer:
"They realized, in a man over 50 years old who has blood in his urine, it is bladder cancer the majority of the time," said Gregory Patton, Doniger's Santa Ana attorney. "The doctor decided that he knew more than urologists do, and he was going to treat it like a kidney stone."

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Plastic surgery and summer break in China

Many college students in China are going under the knife during the summer:
Like a growing number of students in China, Pan Ou will spend her university vacation going under the knife in a plastic surgery procedure she hopes will boost her chances of getting a good job after graduation . . .

. . . The EverCare in Beijing is one of thousands of plastic surgery clinics mushrooming across China with promises to make patients more beautiful, more successful and more marriageable.

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More medical top 10 lists

Another medical top 10 list - this time, the most likely misdiagnosed diseases.

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Big surprise, liability concerns are deterring medical students from OB/GYN

According to a recent survey in Florida:
Of the students who considered ob/gyn but decided against it, 32 percent ranked "fear of malpractice" as the first or second deterrent to entering the field, compared to 21 percent who never considered ob/gyn. Nearly 27 percent of students who considered ob/gyn ranked "fear of being sued" as a first or second deterrent compared to 7 percent who never considered the specialty.

"It appears that some students may have chosen ob/gyn except for the fear of high malpractice insurance costs and lawsuits are associated with our field of medicine," Dr. Deutsch said.

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The President of Uruguay is also a practicing oncologist

He spends a morning a week in clinic:
At the clinic, which is affiliated with the country'’s best-known private hospital, Dr. Vazquez wears a white smock with his name embroidered on a pocket. His colleagues, men and women alike, greet him with a kiss on the cheek, as is the custom here, and address him as "Doctor" rather than "Mr. President."

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"Rising medical costs have been largely justified"

Cutler with a policy piece in the NEJM. Matthew Holt dissents.

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Segregating medicine along religious lines

More religion-based OB/GYN practices are popping up:
The center is one of a small but growing number of practices around the country that tailor the care they provide to the religious beliefs of their doctors, shunning birth-control and morning-after pills, IUDs and other contraceptive devices, sterilizations, and abortions, as well as in vitro fertilization. Instead, doctors offer "natural family planning" -- teaching couples to monitor a woman's temperature and other bodily signals to time intercourse.

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Wednesday, August 30, 2006

Flea chastises an ER doc for overtreatment

Flea must be quite the intimidator to make an ER doc cry.

I'm going to side with the ER doc on this. Over the phone, you can't make an accurate assessment of the patient and thus, it's tough to call the shots on what tests should and shouldn't be ordered. If something happens to the patient, it's the ER physician's responsibility (and liability exposure), not the pediatrician on the phone.

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A call to ban fertility treatments for the obese

Can this ever fly here?
The British Fertility Society is recommending women with a body mass index of 36 and over should not be allowed access to fertility treatment.

Underweight women and those classed just as obese (BMI over 29) should be forced to address their weight before starting treatment, the society said.

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Medicine is simply a revenue-driven business

Many offices are starting to charge for administrative requests in this time of declining reimbursement. Hey, that's what you get in a fee-for-service system:
Doctors - particularly primary care doctors - are increasingly billing for services that patients have long expected to get gratis: prescription refills, photocopies of medical records, phone consultations, family medical leave forms, medical disability forms, waivers of insurance premiums, waivers for handicapped plates.

Automotive forms. And life insurance premium forms.

Travel insurance forms.

And now, e-mail responses.

The practice, almost unheard of five years ago, has disgruntled some patients and is starting to come to the attention of consumer advocates, who denounce it as one more sign of a broken-down medical system.

"It shows that healthcare is like any other enterprise: It is revenue-driven," says Arthur Levin, director of the New York City-based Center for Medical Consumers. "The system is moving further and further away from being a public good to one in which the physicians are mere shopkeepers. How many times can they ring up the register?"
You can't practice good medicine if you're out of business. (via SoloDoc)

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Pay primary care by the hour

The physician/author, Robin Cook, explores this idea in the NY Times:
As it is now, insurance companies — following Medicare’s lead — pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family.

A lawyer in general practice is not expected to accept the same low fee he gets for writing a simple will when he writes one that involves complicated business circumstances. Nor does an accountant charge the same amount for a difficult tax return as for an easy one. Why should the work of doctors be assessed this way?

A typical primary care doctor spends slightly more than half of his or her day seeing patients; the other half is spent conferring with specialists, lab technicians and patients’ families, or trying to persuade health insurance companies to cover some needed treatment. This other half of his work day must be considered pro bono. Factor in rising overhead costs (office space, employees and malpractice premiums), and the situation easily becomes untenable.

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Should American doctors offer their services to Al Qaeda members?

Fox News explores this question during this interview regarding a physician accused of treating Al Qaeda members.

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"Medicine uses science, but it is not science"

Reasserting that there are no certainties in medicine:
Montgomery tells us it is important to realize medicine is not a science. We imagine if it's a science, its conclusions and recommendations are certain. They're not, as any honest doctor would tell you.

And curing ourselves of this false quest for an impossible certainty is step one toward having a medicine we can live with and manage.

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Red Sox slugger David Ortiz likely has paroxysmal atrial fibrillation

According to the informed opinions of physicians interviewed in Boston.

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Can CME come back to haunt Bill Frist?

Many physicians fudge their CME requirements. However, they're not running for president:
Senate Majority Leader Bill Frist did not meet all the requirements needed to keep his medical license active - even though he gave paperwork to Tennessee officials indicating that he had, his office acknowledged Tuesday.

Tennessee requires its licensed physicians to complete 40 hours of continuing medical education every two years. Frist, a heart-lung surgeon who is considering a 2008 presidential run, submitted a license renewal with the Tennessee Health Department stating he has fulfilled that requirement.

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Tuesday, August 29, 2006

Addicted to technology

An academic thinks the proliferation of portable devices will lead to lawsuits:
Keeping employees on electronic leashes such as laptops, BlackBerries and other devices that allow them to be constantly connected to the office could soon lead to lawsuits by those who grow addicted to the technology, a U.S. academic warns.
(via digg)

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TIME.com: VA hospitals are the best

Their EMR is a major reason. Although I don't think it works this well:
Most private hospitals can only dream of the futuristic medicine Dr. Divya Shroff practices today. Outside an elderly patient's room, the attending physician gathers her residents around a wireless laptop propped on a mobile cart. Shroff accesses the patient's entire medical history--a stack of paper in most private hospitals. And instead of trekking to the radiology lab to view the latest X-ray, she brings it up on her computer screen. While Shroff is visiting the patient, a resident types in a request for pain medication, then punches the SEND button. Seconds later, the printer in the hospital pharmacy spits out the order. The druggist stuffs a plastic bag of pills into what looks like a tiny space capsule, then shoots it up to the ward in a vacuum tube. By the time Shroff wheels away her computer, a nurse walks up with the drugs.

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You can't test everyone for West Nile

Apparently some doctors "have to be prompted" to test:
Lisa, who declined to give her last name for privacy reasons, said her physician thought her symptoms were typical of the virus that causes mononucleosis, and only tested for West Nile when she prompted him to do so.

Dr. Henry Lim, who operates a family practice on the Mountain, said he did not initially recognize the symptoms despite having seen a case of West Nile virus a couple years ago.

"It's a very difficult diagnosis to make. You don't want to test everybody who comes in with a cold," Lim said in a telephone interview. "Other doctors are missing it too."

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Beware hair dye allergies

It can lead to significant scarring and hair loss.

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How two doctors use computers differently

Check out these stark differences.

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Common sense tips when visiting your doctor

Make sure you understand what your doctor is saying is probably the most important.

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The long road for the cervical cancer vaccine

Read about its 70-year journey to fruition.

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The fear of stopping futile dialysis

Lawsuits and misconceptions on futile care are reasons:
"The renal-care team has the right to refuse to offer dialysis when the expected benefits do not justify the risks," Dr. Moss said. At his home institution, Dr. Moss is taking a more hard-line approach, saying no to families who request what he believes is inappropriate dialysis. At other times, he offers the dialysis, but if the patient doesn'’t improve, it is stopped.

So far he has not been sued, he said, citing thoughtful discussions he has had with family members about what dialysis can and cannot achieve.

But the fear of lawsuits continues to worry many nephrologists who believe that it is safer to provide dialysis. And there remains that old American unwillingness to let people die, even when it is surely their time.

Dr. Valeri, of Columbia, knows this feeling well. If he suggests to relatives that dialysis be withheld for a gravely ill family member, they confuse it with euthanasia. "They think you are just another Kevorkian," he said.

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The misconception of "medical error"

Adverse events are not necessarily caused by medical error:
One problem physicians face, Dr. Gallagher said, is that patients may fail to distinguish errors from unavoidable medical problems.

"I think that often patients assume that any adverse event is due to error," he said. "That’s not so. A vast majority of such events are not errors and not preventable."

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"The Barry White of the medical blogosphere"

And more speculation on what some medbloggers may look like.

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Grand rounds is up

Protect The Airway hosts the weekly best of the medical blogosphere.

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A 93-year old had two angioplasties last week

I wonder if the treatment would have been as aggressive if he wasn't President Ford.

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Monday, August 28, 2006

A man has a new tongue grafted from his buttocks

Tongue-in-cheek indeed. (via FARK.com)

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P4P leads to gaming the system

retired doc points to a recent Annals article showing these unintended consequences.

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Another day . . .

. . . another vehicle that crashes into a doctor's office.

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The folly of single-payer health care

Consider what will happen with the government picking up the tab: "If you think health care is expensive now, just wait until it's free."

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How banning airplane liquids can increase the risk of infection

This is due to drier mucous membranes:
Dehydration can be a real concern for air travelers, especially those with health problems. An airplane cabin at cruising altitude can be drier than the Sahara Desert, with relative humidity between 10 and 20 percent. "You'’re actually more prone to infection because it dries mucous membranes," said Dr. Marc Siegel, an internist and associate professor of medicine at New York University School of Medicine.

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Can music help with post-op recovery?



The NY Times writes on this interesting study being conducted at a PACU near you.

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Sunday, August 27, 2006

"You don't put money in the bank when they're already in college"

Why receiving the cervical cancer vaccine before sexual activity is important.

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Obesity is a class issue

Some out-of-the-box thinking on obesity:
Fat is not a feminist issue, as Susie Orbach once claimed. Fat is a class issue. Rich, educated people are not fat; you see almost no children in private schools who are overweight. Fatness and obesity are directly related to lower education and lower incomes.

What is sad is that at a time when this country is richer than ever and ought to have better schools than ever, we have far more fat people than ever -— a dangerous explosion of flab.
(via FARK.com)

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A neurobiology research gives up his research

And asks animal activists to stop harassing his family. (via FARK.com)

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Charity Doc with a mail fraud warning

Watch out if you're missing a few days of mail.

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Soccer players are storing stem cells to treat future injuries

This is probably going on in other sports:
Players are freezing the cells taken from the umbilical cord blood of their babies as a possible future cure for cartilage and ligament problems. Stem cells can be used to regenerate damaged organs and tissue because they are the earliest form of cells.

The paper quoted one unnamed Premier League player from a northwest club as saying: "We decided to store our new baby’s stem cells for possible future therapeutic reasons, both for our children and possibly for myself."

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Saturday, August 26, 2006

The NEJM takes a soft view of the personal responsibility contract

I like the concept of a "personal responsibility contract", but the NEJM takes exception:
There are well-understood reasons why Medicaid beneficiaries have poorer health indicators and higher rates of noncompliance than many other patients. Poverty results in reduced access to child care, transportation, healthful foods, and exercise facilities, as well as lower literacy, more life crises, and higher rates of untreated psychiatric illnesses. People with fewer experiences of success are less likely than others to believe that they can change their health status. This plan asks the most vulnerable population to do more with less ability to accomplish what we ask of them.

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Those crazy Norwegian doctors

Apparently one doctor arm-wrestles his patients to see if they're fit for driving.

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Dr. Bennett redux?

More obesity firestorm. A physician apologizes after telling it like it is:
Trudy admits she is 5 stone (31.7kg) overweight, but did not want to say what she weighs.

"I know I have a weight problem and it doesn't help my asthma, but it's swings and roundabouts. I can't exercise because of my breathing," she said.

She claimed the doctor had pointed to his mouth and told her: "It's what goes in here".

She told him that she had managed to shed a stone earlier in the year with Slimming World.

"I am overweight, but I don't eat chocolate or cakes. It's just my metabolism.

"My class leader from Slimming World phoned me and wooed me into going back and I am going to prove the doctor wrong," said Trudy. "I am going to show him."

Trudy has since received an unsigned letter of apology to the effect that the doctor was sorry Trudy felt so upset by their discussion about her weight and hoped Slimming World proved the best way to achieving her goal.

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When it comes to plastic surgery, three's not a crowd

It's becoming a group thing:
Gone are the days when patients slipped into a plastic surgeon's office alone and sometimes in disguise for a consultation and, after the surgery, slinked away to a secret location to recover. Now, patients may arrive not only with a wish list of procedures they have seen on TV or researched online, but also flanked by parents, siblings, spouses or partners. Or the wild card: the friend.

For some doctors, having a second person in the room can be extra insurance that the serious information they are trying to impart is being heard. But at times the consultation begins to feel like a shopping trip to Barneys.

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Dr. Id

A Canadian doctor is fined for rudely firing his patients:
The college heard Rathe, who moved to the physician-strapped Windsor suburb of Belle River in 2001, removed from his patient list 328 people he deemed difficult, dismissing some from his practice with "f--- you."

He was physically aggressive with two patients -- he pushed one woman -- and emotionally abusive to others.

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Response to OTC Plan B

Read some responses from New York women.

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Take the medical ethics test

What would you do in the following situation?
Jenna, 18, requests an abortion referral. Because she has irregular periods, she didn't suspect pregnancy until her clothes got tight and the results of a home pregnancy test came out positive.

On exam, her uterus is 16 to 18 weeks in size. The abortion clinic in your town only terminates pregnancies before 12 weeks. You have to request special permission from her HMO to obtain a second-trimester termination elsewhere. You oppose abortion and don't wish to approve termination of a four-month fetus. Jenna says she can't afford a child, can't sleep due to the stress, and wants the abortion quickly, before time runs out.
Part of a series of ethical questions posed by Medical Ecomonics.

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The Lancet wants to scrap "asthma" as a term

The reasoning is as follows:
Asthma is not a single disease, but a group of syndromes with different origins and characteristics and so it is best to scrap the name, it says.

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Dr. Charles with "decorative needles"

Always good for a laugh, Dr. Charles comes up with a few decorative needles of his own.

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Friday, August 25, 2006

Medblog article

Physician's Personal Advisory recently interviewed Medpundit and myself on a recent article about physician blogs: "Blogging offers creative outlet for physicians".

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Thursday, August 24, 2006

More warnings on Advair

A recent letter to the NEJM gives some pause on Advair. The problem is with the salmeterol component, which can lead to clinical worsening if given during an acute asthma attack.