Saturday, September 30, 2006

In-store health clinics start closing

So much for that threat to doctors - they didn't even last a year in Portland, OR:
Rite Aid Corp.'s first experiment offering health clinics inside its stores ended when the clinic operator decided it could not turn a profit.

Take Care Health Systems told Rite Aid that it would close its last seven health clinics on Friday, less than a year after opening 10 of them in Rite Aids around Portland, Ore.
Update:
Link is fixed.

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CP r/o MI, another ER story

Another "ER is too busy, I had to wait" story. Maybe if more of these get published, something can be done about it.

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Government to Ontario doctors: "Hang in there"

At least they acknowledge a shortage as well as reimbursement issues. More than can be said Stateside.

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You think ER docs got it bad here . . .

. . . try Baghdad.

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Jury hits Walgreens with a $31 million verdict after a prescription area

Another jury sending a message. The incident involves giving Glipizide, a diabetes medicine. Noted in the case, was the Oxycontin-addicted pharmacist who stole 86,000 pills over an eight-year period.

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Defensive medicine in action

Occurring daily at an ER near you. The main reason why health care costs are skyrocketing.

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What happens when physician fees are controlled

Demand increases, shortages develop, quality goes down. The road where Medicare is taking us.

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The botched student intubation continued

Thanks to various commenters from the prior post for the links.

Apparently the patient didn't want any student touching her. More details:
Mullins sued because several weeks before the procedure, her surgeon, Dr. Marvin E. Eastlund provided her with an informed consent document on which she indicated she did not want health care students in the operating room.

"Whose responsibility is it when a patient says they don’t want a learner to ensure that?" Chief Justice Randall T. Shepard asked.

The injury occurred when the student tried to intubate Mullins. An intubation is a common medical procedure where a tube is inserted into a patient’s throat to ensure that airways remain open during surgery.

But the damage required a second surgery and required Mullins to spend more than a month in the hospital recovering.

Mullins also signed a document from anesthesiologist Dr. Kathryn Carboneau that said only Carboneau or "a physician privileged to practice" anesthesia care would perform specified duties.
Also, the student was studying to be an EMT and the intubation was part of her training. This case was her first live intubation:
VanHoey made two attempts to intubate Ruth using a laryngoscope. After her second attempt, both Dr. Carboneau and Dr. Eastlund saw blood on the type of the laryngoscope, but apparently, the presence of blood on the laryngoscope following intubation is not unusual, and neither doctor was alarmed at the time. After VanHoey failed to intubate Ruth successfully, Dr. Carboneau performed the procedure and completed Ruth’s anesthesia.

On December 6, 2000, two days after Ruth’s hysterectomy, the attending nurse noticed that Ruth’s face and neck were beginning to swell. After running some tests, Dr. Carboneau, Dr. Eastlund, and Dr. John Csicsko, a cardiovascular surgeon, met with Ruth to explain that VanHoey had lacerated Ruth’s esophagus when she attempted to perform the intubation procedure. The doctors explained to Ruth that she needed to undergo another surgical procedure to repair the damage to her esophagus. Although Ruth was reluctant to undergo another surgical procedure because she had just undergone the hysterectomy, the doctors strongly encouraged her to have the procedure that day because waiting until the next day could have been fatal. Thus, on the same day, Ruth had surgery to repair her esophagus, and as a result of this second procedure, she had to remain in the hospital for over a month until her dismissal on January 5, 2001.
More than the issue of battery, is the issue of consent - which the patient clearly stated that she didn't want any teaching to be done on her.

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Friday, September 29, 2006

Medical care in Belgium

Certainly a world of difference compared to what happens here:
This was the beginning of a series of happy discoveries about medical care in Belgium. Healthcare in the US is mired in bureaucracy and competing interests and concerns about liability. It's a complex system that both doctors and patients hate for different reasons. The typical doctor must employ a receptionist to handle calls and appointments, an office manager to handle the business side (accounts receivable and insurance claims), and at least one nurse to assist the doctor and patients.

A typical doctor's visit always includes filling out paperwork, updating your medical history, submitting insurance information and waiting, waiting, and waiting to see the doctor, who is normally overworked and visibly frazzled by the incredible pace and hours he/she is expected to keep.

After 18 months in Belgium and multiple checkups, I have yet to fill out a single form, let alone the scads of paperwork I had to do in the US at every single visit. All of my medical tests have been given by doctors; in the US specially trained technicians or nurses administer tests and the results are reviewed by the doctor later.

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Chiropractic quackery

So much for time travel being a valid therapy:
State regulators had been investigating Dr. James Burda of Athens, who said he could take care of anyone, anywhere by reaching back in time to when the injury occurred.

Burda said he discovered the skill six years ago when he hurt his own foot while driving. He said he gave the pain a command to stop and it went away.

He said he doesn't use force to realign bones, but he uses his mind to manipulate the body. But if that doesn't work, he said he travels back in time to fix the problem. He calls the practice Bala-Keem. State medical officials call it malpractice.

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Malpractice war in Florida heats up

Lawyers sidestep a voter-approved constitutional malpractice cap. Doctors are asking patients to sign a form waiving their rights to to collect anything more than $250,000 in a medical malpractice lawsuit:
"We cannot allow trial lawyers to circumvent the will of the people through their legal maneuvering," said Patrick Hutton, president of the Florida Medical Association and an orthopedic surgeon from the Jacksonville area.

Hutton and other FMA officials were quick to stress that the waiver won't be required in emergency cases. But they didn't rule out the possibility that some doctors may refuse to treat patients who don't want to sign the form.

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Thursday, September 28, 2006

You can't sue a doctor for a medical bill

Some patients think they can sue doctors for anything. Like this story over medical bills:
Out of the blue, we received a bill for $300 from a collection agency from the former neurologist. I recently wrote to the doctor and told her what had transpired and how we felt we owe her nothing.

We know we could have pursued a medical malpractice claim but choose not to, but can Action Express help us with the bill?

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A woman claims battery after a medical student botched an intubation

Having medical students intubate during elective procedures, under supervision of an anesthesiologist, is common practice. However, this patient specifically wanted no medical students, but the hospital ignored her wishes:
The Indiana Supreme Court is considering whether a woman who had to have a second surgery after a medical student tore her esophagus during a botched procedure was a victim of battery.
Attorneys for W- Ruth Mullins say she signed documents saying she didn't want students in the operating room, but doctors ignored her wishes.

Her attorney, Sherrill Colvin, says the case fits the definition of battery because harm resulted after the student inserted a tube in Mullins' throat.

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GM: "If we ran an auto plant like they run hospitals, we'd be out of business"

I don't think almost-bankrupt General Motors is really in a place where they should be telling anybody how to run things.

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Here come the spinach lawsuits

I'm surprised it took this long.

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Dr. Charles on family physicians

More challenges facing primary care. Why do I get the feeling this is just protesting on the Titanic?

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BREAKING NEWS: ERs are overcrowded

Sorry, this is not news at all - as readers here already know.

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Hospitals are rising to fight insurance companies

I'm happy to see the hospitals developing a backbone. Someone has to fight against reimbursement extortion that the insurance monopolies are applying. Notably, UnitedHealth is involved in many of these disputes.

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The biggest problem drug in Worker's Comp

It is Actiq, which is transmucosal fentanyl. Apparently this expensive drug is routinely being prescribed for musculoskeletal conditions.

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Truths in the ER

Scalpel or Sword (newly added to the blogroll) lists a few. (via GruntDoc)

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A 5-year old dies after a routine dental procedure

Any anesthesiologists out there care to speculate on what could of happened?
Travis has said the dental staff gave Diamond a liquid sedative, followed by nitrous oxide and intravenous sedation. Travis said she entered the office after the procedure and saw her daughter lying motionless on her side in a dentist chair.

The girl's head was rolled back, her eyes were in the back of her head and she wasn't breathing, Travis said.

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Wednesday, September 27, 2006

Medicare, RVUs and steakhouses

Another example showing the ridiculousness of the Medicare RVU system:
And even worse, the insurance companies use the Medicare RVUs to set their rates, so everyone is socialized. If the government told all restaurants that they could only charge $10 for a steak dinner, whether they were Golden Corral or Smith and Wollensky's, what do you think would happen to the quality of the dining experience? Is that really what we want our country to be like?

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Internal medicine recertification is getting more difficult

Only 74 percent are passing recertification their first try.

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The average Medicare patient sees seven physicians over a 2-year period

This includes two primary care and five specialists. This sort of fragmented age presents another barrier for P4P, and is reflective of the bloat plaguing American health care.

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More on the folly of cutting physician reimbursement

It never works to save money. This will lead to an increase in the volume of procedures, further driving up health care costs:
When physician fees are capped, the number and complexity (or volume and intensity) of services furnished to Medicare beneficiaries simply increase, including more frequent and intensive office visits, and a rapid increase in the use of imaging techniques, laboratory services, and physician-administered drugs, which will lead to price caps on pills and procedures in fairly short order. (According to a study by the World Bank, for every dollar that price controls reduce doctors’ fees under Medicare, physicians recoup 40 cents by increasing volume.)

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More hospitals are banning videotaping and photos during childbirth

Of course, liability is the reason. Patients lose again:
Florida Hospital and Orlando Regional officials agree liability is a factor, though they emphasize safety as their main concern. But Bair at Central Florida Regional said that hospital's policy was prompted by worries that a photo or videotape could end up as evidence in a trial.

A birth video last year helped lead to a malpractice settlement in Missouri, attorney James Guirl said. The case involved a child who suffered an arm injury during delivery. But birth videos tend to be taken at discreet angles, he said, so it's rare for them to be very useful in a legal case.

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A burglar sues a doctor after breaking into his house

Apparently the doctor used "excessive force" as he shot the burglar in his home:
An accused burglar is suing the doctor who shot him after the man broke into the physician's house in Janesville.

The man is awaiting trial on charges of burglary and criminal damage. In the meantime, he's filed suit against Doctor Michael Rainiero. He claims Rainiero was negligent in using excessive force after he found the man in his home. The man was shot in the back. The lawsuit says he suffered "severe and permanent injuries."

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A shortage of PCPs

Family medicine applications plummet while the need continues to rise. Readers of this blog know why.

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Number needed to treat

Slate with a nice article on NNT - a statistic that is not advertised in many pharmaceutical studies:
In June, the New York Times ran an article headlined, "Breast-Feed or Else." It suggested that experts believe that "breast-fed babies are at lower risk for sudden infant death syndrome and serious chronic diseases later in life, including asthma, diabetes, leukemia and some forms of lymphoma." Yet, the article never mentions the NNT for breast-feeding to prevent these scary diseases. Neither does any general-interest press article in LexisNexis, a database. There's a reason for this omission: The NNTs are astronomically high. Reasonable women might think that breast-feeding isn't worth the trouble—a conclusion that you don't want drawn if you're promoting breast-feeding at any cost.

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The cliche of spiraling health-care costs

Yes, health care is expensive. But so is added life expectancy:
Instead, a baby born in the United States this year will live to age 78 on average, a decade longer than the average baby born in 1950. People who have already made it to their 40’s can now expect to reach age 80. These gains are probably bigger than the ones the British experienced in the entire millennium leading up to 1800. If you think about this as the return on the investments in medicine, the payoff has been fabulous: Would you prefer spending an extra $5,500 on health care every year — or losing 10 years off your lifespan?
Now, people are sacrificing life expectancy to save on health costs:
"You almost always spend money to gain health." Of course, the opposite is also true: the best way to reduce health care spending is to reduce health care itself.

Which is exactly what we’re starting to do. The growing number of families without health insurance are, in effect, families who have been kicked off the country’s health care rolls. Many will go without available treatment, will get sicker than they need to get — and will thereby save the rest of us money. They are what now passes for a solution to the health care mess.

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Find the wire

Dr. Schwab with a "mammorable" patient and a lost wire. Another great story.

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Tuesday, September 26, 2006

Medical tourism: Malpractice caps = lower medical costs

The effect of malpractice caps on medical costs, one reason why medical tourism is so cost-efficient:
Malpractice expenses also are much lower. People can file claims in Costa Rican courts, he said, but they generally are encouraged to settle rather than go to trial.

The story in Bangkok is similar.

At Bumrungrad Hospital, Mr. Toral said, the lower cost of living is a major factor in the savings, but so are differences in how the medical system operates.

Doctors in Thailand pay about $5,000 a year for malpractice insurance, compared with more than $100,000 for some specialties in the United States.

Thai courts will adjudicate malpractice claims, but the largest award ever issued was about $100,000, Mr. Toral said, and the law there doesn't permit damages for pain and suffering.
(via Overlawyered)

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Patients' insurance affects clinical decision making

The uninsured tended to be prescribed more generic medications:
According to the survey, 88 percent of the doctors made at least one change in their patients' clinical management due to his or her insurance status. Overall, physicians changed management strategies for 99 of 409 patients. Nearly two-thirds (62.6 percent) of the time, doctors discussed insurance issues with patients and made changes based on insurance status.

Common changes in practice included prescribing two separate generic medicines instead of one brand-name combination pill, or using a less expensive but longer course of medication. Both strategies make it more likely that a patient will not keep up with the prescribed regimen, the researchers noted.

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Replicating the "Super Size Me" diet



A study in Sweden wonders what would really happen if people ate 6,000 calories per day.

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Dr. Crippen on the Memorial mercy killing case

A view from across the pond.

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Digg and del.icio.us

I have added the ability to share posts via Digg and del.icio.us. Enjoy.

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The reality of consumer-driven health plans

Take this story from a small automotive company. The boss is really knowing more employee health information than he ought to:
Mr. Bond's experience suggests that although information about the price and quality of health care remains sketchy, the president's push to make the health-care market more like the market for other services can change consumers' behavior. However, some managers have to turn themselves into instant experts both on health care and on the law. Mr. Bond knows about a transmission rebuilder's heartburn, a technician's blood-pressure medication and a visit to the emergency room by a mechanic's daughter. If he uses health information in firing or demoting an employee -- or is perceived to do so -- he might be in for a lawsuit.

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More Canadian ER woes

It has become so desperate that Canadian community hospitals are contracting for-profit corporations to run their ERs.

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Too bad that Medicare wants to cut reimbursements for house calls

Once again, by cutting reimbursement, patients lose and health care costs go up:
Current proposals before Congress could reduce those reimbursement rates, however, making home visits a less attractive option for doctors.

That would be a shame, because one of the fastest-growing segments of the U.S. population is those 85 and up. Many are, like Kurzweil's mother, frail and in need of multiple medications and frequent doctor's care. Since it's hard to get around, they often delay seeking treatment until an illness is full blown and then call 911. That becomes time consuming and costly and can lead to a family crisis. "When elderly patients go to the emergency room, doctors are very uncomfortable about sending them home" right away, says Dr. Joseph W. Spooner of Care Level Management in Woodland Hills, Calif. "So they admit them, and patients stay three or four days."

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A doctor shortage forces a surgeon to keep working

Only going to get worse as the population ages.

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A pathologist is sued after giving a false autopsy report

His work is being reviewed by an independent panel.

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A 24-year old bleeds out after a tonsillectomy

A case report in the NY Times no less. Scary complication of a fairly routine procedure.

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Another symptom of the rushed office visit

Apparently, most doctors don't explain the medications they are describing.

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Ear pain and screaming: Not a pediatric emergency

More good information from Flea.

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The anniversary edition of Grand Rounds is up

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

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Monday, September 25, 2006

The egg-timer office visit

Sad, but not surprising - as doctors cram more patients they see during the day, staying on time is a must:
Some of Dr. Trent Dusang's patients have transferred their medical care over to him because their old doctors would set an egg timer at the beginning of their visit, then leave when the buzzer went. Time was up . . .

. . . While egg buzzers in doctors' offices are rare, more doctors are posting signs asking patients to limit the number of medical issues dealt with in a single office visit to one.

One woman, who had trusted her doctor with her health and that of her family for 25 years, complained to the College of Physicians and Surgeons of Alberta. She had been discharged from the doctor's practice because she often came in with more than one health problem.

The sign in her doctor's office read: "Due to a significant increase in patient waiting times, the doctors in this office will ONLY deal with ONE medical problem per office visit. If you are not in agreement with this policy, we will be pleased to transfer your medical record to another physician of your choice."

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Shoddy prison medicine

Don't get sick while in jail. Or better yet, just stay out of jail.

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The penis-mangling cardiothoracic surgeon

There is no good cosmetic surgery for penis enlargement. Especially from this surgeon:
Burman, 80, was once a well-respected heart surgeon until a 1981 car accident limited his mobility and he began operating on penises.

He said he is self-taught in the procedure and has no formal background in urology or plastic surgery.

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Why physicians don't use email

Is email doomed to concierge practices only? Seems that way:
Some health plans have begun reimbursing doctors who interact with patients on specially created Web sites, but the numbers are still negligible. For the most part, doctors are not paid unless they see patients face to face.

In their offices, doctors are under constant pressure to curtail time spent with patients, said Marcy Zwelling-Aamot, an internist with a private practice and former president of the Los Angeles County Medical Association. The last thing most of them want is to give patients another way to get a hold of them.

"They don't want to be bombarded," said Zwelling-Aamot, who runs a concierge practice, meaning she doesn't take insurance. Her patients pay her $1,500 a year for full access to her services, including e-mail consultation.

But "I have 500 patients," she said. Other doctors may "have 3,000 patients."

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