Thursday, November 30, 2006

Emergency Chinese if you have GI symptoms in China

Good to keep handy when travelling to China.

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Are medical specialists biased?

Of course they are, says this doctor:
Now, it's a mathematical certainty (and simple common-sense) that the more the tests you perform, the higher the likelihood that at least one will be abnormal. If you perform a panel of over 20 tests for any woman, at least one (or even more) are going to be "abnormal". This condition, when the result of the test is abnormal, but the patient is normal, is called a "false positive test". Unfortunately, because specialists are biased and often have blinkers on, they treat all abnormalities as true positives. He is very pleased that he has finally "diagnosed" the elusive problem - and then goes about treating it. Actually, the abnormal test result is just a red herring which has little to do with the illness - but the patient is also equally pleased that this new expert has cleverly found the problem which all the earlier experts has "missed".

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A doctor gives a woman 300mg of IV Phenergan for nausea

This is a lethal dose. An osteopathic surgeon (not exactly sure what that is - a DO perhaps?) had to change his name due to the 110 other malpractice suits against him.

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Racial differences in end-of-life care

A study suggests that black patients are more likely than white patients to prefer life-sustaining care when confronted with an incurable illness or serious mental and physical disabilities.

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Hospitals banning cellphones for profit?

Recent studies have demonstrated the safety of cellphones in the hospitals. Banning them forces patients to pay the hospital for telephone access:
But it reveals that Health Service authorities have prohibited their use after signing deals with private telephone providers.

These firms, which have installed bedside entertainment systems under the Government's 'Patient Power' policy, have made millions by charging up to 75p a minute for incoming calls from mobiles and 49p from landlines.

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An 11 year-old boy with leukemia is selling ad space on his forehead

He wants to raise money for the Bone Marrow Registry:
The sixth-grader said many people have visited his Web site but there have been no bidders.

"I hope that people start bidding on it now, before it ends Dec. 6 and that's all I can hope for," Pedraja said. "Bidding will not only help you by advertising, it will also help save a bunch of lives."

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Confessions of a phlebotomist

Some stories from the hospital "vampires":
It never seems to amaze me in the winter, people walk in with the big, bulk coat sit in the draw chair, and then say "oh, do I have to take my coat off?" how do you expect me to get the blood, I love to say, "no keep the coat on, it may take me 15 times to hit the vein, but I get it eventually."

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An EMT punches a psychiatric patient

No matter what the circumstance, this is not allowed.

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Physicians and conflict of interest: Patients don't care

A vast majority just want to get better:
Medical and professional societies have increasingly urged doctors to reveal all such conflicts of interest so patients can judge whether their doctor may have more than their health at heart. But perhaps because they are already overwhelmed by the challenges of their disease, most patients said they did not need to know those details and trusted that rules were in place to protect them.

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So, does $41 billion help with wait times in Canada?

Uh, they don't seem to know.

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Hooray New Hampshire!

First state to offer the HPV vaccine free to girls 11 to 18. It's nice to be in the Granite State.

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A health risk of prayer

Praying-induced oromandibular dystonia:
This general kind of problem is called "focal dystonia". It's the involuntary fluttering of muscles that one ordinarily controls masterfully. It arises, somewhat mysteriously, in a few extraordinarily unlucky people who perform "a highly stereotyped and frequently repeated motor task". It's what happens in writer's cramp, and in the eyelid twitching known as blepharospasm, and very occasionally in certain specialised professions. Doctors have seen it in pianists, tailors and assembly-line workers. But never before in someone whose repetitive action consisted only of saying prayers.

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Importance of a second opinion

Eye-opening stat. More than half of breast cancer patients had their treatment plan changed after being reviewed by a tumor board:
Researchers looked at the records of 149 consecutive patients referred to the U-M Cancer Center’s multidisciplinary breast tumor board for a second opinion. The patients had already been diagnosed with breast cancer after having undergone initial evaluation, breast imaging and biopsy, and they already had a treatment recommendation from another hospital or care provider.

Overall, 52 percent of the patients evaluated had one or more changes in their recommendations for surgery. The changes were a result of breast imaging specialists reading a mammogram differently or breast pathologists interpreting biopsy results differently. In some cases, the initial recommendation was changed after the case was reviewed by medical oncologists and radiation oncologists prior to surgery.

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"Everyone wants to be a plasticologist"

More doctors are leaving their fields for cosmetic medicine. Blame Medicare and third-party reimbursement for this:
Five years ago, cosmetic medicine was primarily the domain of plastic surgeons, facial surgeons and dermatologists — medical school graduates who undergo several years of training in facial skin and its underlying anatomy. But now obstetricians, family practitioners and emergency room physicians are gravitating to the beauty business, lured by lucrative cosmetic treatments that require same-day payments because they are not covered by insurance and by a medical practice without bothersome midnight emergency calls.

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UK's P4P from the front lines

Dr. Crippen says doctors are in a no-win PR position:
My pay has gone up approximately 25% over the last two years. That extra money has been earned by hitting government targets. The targets were set by the government, not by us, and mostly have little to do with health care, but a lot to do with “process” and bogus but quantifiable “healthcare achievements”.

We told the government at the outset that it was a waste of money, that the money could be better spent but, to them, “control” was everything.

They removed our professional autonomy. They told us what to do, and promised us piece-rate financial rewards for doing it. So we have done it, and done it more efficiently than they thought possible.

This was always a lose-lose PR exercise for doctors. If we had not hit the targets, we would have been lazy. If we hit them, we are greedy.

All targets hit. All payments made. Healthcare continues to deteriorate. So the government need a scapegoat. Everything has gone wrong. You do not know where all the money has gone. Let us blame the doctors. This is bunker mentality. You lose the war, so it is time to start shooting the soldiers.

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Better than the real thing?

Pillowy SSRIs:



(via Unbounded Medicine)

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Wednesday, November 29, 2006

Goodbye Google Answers

Google Answers announced that it is shutting down. This 4-year old service comprised a passionate community of 800 or so researchers answering questions of all varieties.

Although I haven't been an active researcher recently, it is where I got my "start", so to speak. It opened up web-related avenues for me, ranging from Med Help to this blog you're reading.

So, thanks Google Answers and goodbye. Feel free to read the other retrospectives.

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P4P in UK leads to an increase of 30% in physician salary

Can this be a viable way to increase primary care compensation, thus re-attracting medical students to the field?

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Health care today: Payment and fear of malpractice takes priority

Well, it definitely isn't like it used to be:
The first question I get asked when I pursue medical treatment is who is your insurance company and the responsible party. There is no one who is willing to give you any simple advice or reassurance for fear of being blamed for wrongdoing or sued for malpractice. The doctor that I had for 25 years, all my adult life, recently quit taking my insurance provider. Sure, I could pay out of pocket for office calls or non-catastrophic expenses in order to stay with him, but what if the “big one” does hit? Then what?

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Instant first aid

Some good tips when an ER or doctor isn't handy, like rubbing an onion on first-degree burns.

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Lawyers in the ER

Are they reluctant to tell physicians their profession? GruntDoc thinks so:
The most reticent to tell me what they do are lawyers (and I'm just guessing here, but if I was a lawyer in an ED I'd worry a little that I'd get over-tested and overdiagnosed due to medmal paranoia . . .

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Changing genders, without surgery

It's causing all sorts of confusion and dilemmas:
New York City appears to be on the forefront when it comes to transgender rights. Last month, the agency that runs the subway system agreed to allow transgender people to use the restrooms of their choice. Now comes news that the city will probably allow people born there to switch the gender on their birth certificates.

According to a proposal that's expected to be approved next month, the city will allow the changes if a person brings documentation from a doctor and meets some other criteria. No surgery is necessary.
btw - here are some prices for various sex-change procedures.

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Why it's difficult to apply business techniques to medicine

Medicine has too much variability, says Aggravated DocSurg, and can't be compared to flying a plane:
Now let's compare the pilot to, oh, I don't know, a general surgeon (what I lack in imagination is made up by a complete deficiency of imagination), and that surgeon will do four operations today. The first is a laparoscopic cholecystectomy on a healthy 50 year old; the second is an incisional hernia repair on an obese, diabetic, hypertensive 70 year old; the third is a colectomy for cancer on a reasonably healthy 65 year old, who had an MI last year; and the fourth is an urgent laparoscopic cholecystectomy --- but that patient is put at the end of the day, because she is on Coumadin and needs to have her anticoagulation reversed, carefully though because of her CHF. Please don't laugh --- I have these types of days not infrequently.

That, to my way of thinking, is sort of having the pilot above start out flying on a nice sunny day in a 737, switching to an aging 747 that's not in the best of shape for the next flight, flying as carefully and straight in a thunderstorm for the third flight, and then trying to safely land a Sopwith Camel with one wheel missing at the end of the fourth flight.
See also Medrants who comments.

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Flea on retail-health clinics

He takes exception with the AAP's reasons for opposing these clinics. I think this physician commenter truthfully explains the cause of the fear:
The big threat to us is that they cut into our biggest financial gain - the 2-minute visit. I make way more in 10 2-minute visits than I do 2 diabetic checks. I don't want to give our "bread and butter" (when it comes to revenue) to someone else and be left with the difficult longer visits.
I agree that they are likely here to stay for the long term. Partnering with them, rather than pushing them away, would seem to be the prudent strategy. Many of RBC utilizers may not have PCPs, and can be used as a referral source.

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A doctor prescribes ampicillin for every infection

Observes someone who works at a pharmacy. It's either ampicillin or ibuprofen. The more interesting observation is that these same patients often later return with prescriptions for broader-spectrum antibiotics, prescribed by the ER.

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Bloodbath at Pfizer

PharmaGossip with more on the sales force cutdowns.

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Tips for convincing your doctor to order more tests for you

TBTAM reports on the HPV test and how to convince your doctor to order tests you may not need. However, with ancillary tests bringing in revenue, doctors may not need much convincing.

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When patients threaten to leave AMA

A urologist reports a bizarre case, which is reason enough to read. However, when patients threaten to leave AMA, they act as if this is some kind of threat against us. Trust me, it makes no difference to the doctors if they chose the path against medical advice.

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Tuesday, November 28, 2006

Is Matthew Holt on the Kaiser payroll?

Let the conspiracy theories begin. This anti-Kaiser website suggests Kaiser is paying off Holt to be a token "blogging presence" during this PR event in the midst of their EHR debacle.

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Mom microwaves baby

This news comes out the same week that a man puts a baby in the freezer. Sick.

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The three leading killers in the year 2030

From the WHO: AIDS, heart disease and depression.

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"Cutting down" smoking isn't enough

You have to quit completely.

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Rude doctors

Dr. Malpani offers some insight:
For one thing, doctors in hospitals are very busy and they often just don't have time for the common pleasantries which we take for granted in our daily life. Many of them are brusque and down-to-earth because they need to get on with their serious job of taking care of their patients, and they simply cannot afford to chit-chat with patients or their relatives. This is why they put on a shield which protects them from having to spend too much time with one patient. They cultivate an aura of superiority and aloofness to allow themselves to accomplish their tasks effectively.

They are usually accompanied by a retinue of assistants and juniors - and they often spend more time talking to them than to patients. Since nurses and juniors are deferential and respectful, patients are expected to toe the line and follow suit.

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"It’s always easier to order a test than to have a conversation about why the harms of the test outweigh the potential benefits"

Which is why PSAs continue to be ordered in 85 year-old men.

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The cold hospital environment

Another nice NY Times essay. The benefits of an impersonal hospital environment, and why doctors don't cry:
Monitoring the potassium, adjusting the antibiotics, getting the latest scan result — this is a full-time job, enough to keep a patient and family completely distracted from the awful truth. The welter of information, so much of it useless, is the accidental genius of our current health care system.

And it works — witness the difficulty so many face with dying at home. Almost everyone confronted with the choice expresses the wish to die among familiar surroundings. All the necessary pieces — visiting professional care, a hospital bed, an I.V. pole, the works — can be gathered with relative ease.

Yet frequently, it gets too, well, emotional. Sitting in a den or dining room awaiting death is too intimate, too personal, the free-fall toward the end too breathtaking.

So patient and family return to the bustle and insensitive self-importance of the hospital. And they get the full monty: the reassuring whir and hurry of blood samples run at all hours, portable X-rays taken in the next bed, scratchy announcements over the loudspeaker.

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Donating money to patients

NY Times' Abigail Zuger on giving money to patients:
I still indulge in fantasies of saving my needy patient with a solid hunk of cash, an anonymous check — enough to buy her food and transportation; expert, consistent medical care; a few treats; and a little something in the bank.

It is an idiotic fantasy. But perhaps no more idiotic than for me to write out checks this month that will cover an infinitesimal fraction of some giant charity’s overhead. No more idiotic than for me to labor over Latin incantations on little scraps of paper in the illusion that they alone will make a difference in my patient’s health and life.

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Grand rounds is up

Notes from Dr. RW hosts this week. Come get the weekly best of the medical blogosphere.

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Cover-up at the BBC

Dr. Crippen exposes some shoddy reporting, and subsequent covering of tracks, over at the BBC.

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Homeopathy and placebo controlled studies

Why do you use as a placebo versus homeopathic treatment? Orac discusses the excuse of why homeopathic treatments are not conducive to double-blind, placebo-controlled studies.

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Monday, November 27, 2006

"No beginning physician could afford to cover the liability risks of today, alone"

A town loses it's orthopedic surgeons to retirement. They could not recruit others, which causes this OB to lament:
I arrived at the office from the hospital at noon on a January day and began to look at the mail on my desk. On the top was the bill for my liability insurance coverage for the coming year, necessary for defense against lawsuits. The amount was a startling increase, very close to my take-home pay the previous year. I wasn’t willing to play the game, to let corporate structure tell me how, as a trained professional, where, when and under what circumstances I might practice medicine.

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Appeasing social conservatives: "It's losing politics"

Behind Bush's anti-science family planning office appointee:
As medical director of A Woman's Concern, a small chain of nonprofit pregnancy counseling clinics that offer no information on birth control, Keroack has agitated against abortion and even contraception — including for married women. The organization continues to push the discredited nonsense that abortion increases a woman's chances of breast cancer and is more dangerous during the first eight weeks of pregnancy (when, in fact, the risk of complication is actually at its lowest). Birth control, according to A Woman's Concern's tortured logic, is somehow "demeaning to women." And Keroack has argued that women who have sex with multiple partners alter their brain chemistry in the process, making it harder for them to form close relationships.

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Behind the Libby Zion case

The landmark malpractice case that led to regulation of medical residents' hours. Sad to say, the situation described in 1984 could have easily happened when I was a medicine intern in 1999. My very first rotation, a week out of medical school, was the night float intern. One week, I was a 4th year medical student. The next, I was cross-covering 60 patients overnight. Scary.

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The uninsured patient experiment

This blog tries to find out payment plans and pricing from a variety of hospitals. Here's what he found when posing as an uninsured patient requesting an elective CT scan:
* The list price varies by 75% ($1,013 to $3,970).
* The best uninsured price varies by 92% ($204 to $2,600).
* List price discounts range from 0% to 86%.
* To get many of the discounts hospitals offer the balance needs to be paid in full at the time of service or a large down payment made, to receive it.
* Some hospitals are unwilling to divulge the price over the phone and others will not call back.

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Can money buy happiness?

Maybe just a bit, says this recent study:
In one study, they said, people with household incomes of $90,000 or more were only slightly more likely to call themselves very happy over all than were people from households making $50,000 to $89,999 — 43 percent to 42 percent. (Members of the first group were nearly twice as likely to be "very happy" as people from households with incomes below $20,000.)

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From medicine to Wall Street

Physicians are jumping from a sinking ship to the lure of riches:
"There were doctors at the reunion — very, very smart people," Dr. Glassman recalled in a recent interview. "They went to the top programs, they remained true to their ethics and really had very pure goals. And then they went to the 20th-year reunion and saw that somebody else who was 10 times less smart was making much more money."

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Why do patients take alternative medications?

The BMJ explains why:
Waxman believes that it is because the complementary therapists offer something that doctors cannot offer – hope. If you eat this, take that, avoid this, and really believe this then we can promise you sincerely that you will be cured.

And if the patient is not cured, it is the patient who has failed, not the alternative therapy. The patient has let down the alternative practitioner and disappointed his family who have encouraged his "treatment."

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Dr. Sanjay Gupta: Celebrity superdoc



(via At the End of the Boom)

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Denying jobs to smokers

Some employers are resorting to urine tests to screen out smokers from jobs:
Some enforce the policy by requiring a urine sample from prospective employees. If the urine cotinine level exceeds the threshold that indicates active smoking, then the applicant is automatically rejected for the position, regardless of his or her qualifications for employment. Several of these employers go so far as to fire existing smokers if they are unable to or uninterested in quitting within a given time period.
This doctor goes further and suggests screening out those who have been exposed to second-hand smoke.

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More on why health courts make sense

I still don't know how juries and judges are able to sort out all the expert testimony during sometimes highly nuanced malpractice cases:
Doctors and lawyers are rarely cross-trained in each other's professions, posing a problem when crucial decisions need to be made that are beyond one's specialty. Fear of litigation may prompt physicians to order excessive precautionary tests and procedures, while judges with no medical training must weigh the testimonies of competing experts.

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$913 for removing earwax

The explanation: "Because the instrument used in the cleaning process is considered a surgical instrument, the procedure is considered to be surgery."

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