Saturday, March 31, 2007

Why is everybody so angry at doctors?

Edwin Leap tries to make sense of it:
No one bats an eye at television shows about rappers or athletes and their elaborate homes, or extensive car collections.

But doctors! Oh my! One reader commented on my column on free care with a very annoyed letter to the editor, ranting about doctors and their six figure salaries. But what about seven figure salaries of football players? What about the six figure salaries of contractors, brokers, owners of car dealerships, plumbers, researchers or academics? Are they inherently evil?
(via GruntDoc)

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Health care is not a right

Eric Novack in an op-ed:
Just as it is morally repugnant for employers or the government to require workers to work extra hours without pay, it is unethical for a society that cherishes freedom to create a system where a right to health care obligates doctors to provide care at any time, and for a price that is dictated by government.
(via The Health Care Blog)

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Friday, March 30, 2007

"Working where the sun don't shine"

An ode to the colorectal surgeon.

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Ecstasy commercial

A parody of the Zoloft TV ad. More weekend hilarity, via Mad TV.

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"In my white coat"

Courtesy of the Howard University College of Medicine.

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P4P measures causing harm

Roy Poses outlines two instances where suggested P4P measures can lead to more harm than good.

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Does the ACP covertly want a single payer system?

retired doc feels that the ACP's "medical home" solution only would work within a single payer construct.

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Broken rib: $12,000

The tab started before he got to the hospital:
On the other hand, what Palmer didn't know is that as soon as the paramedics radioed ahead to say they were bringing in an accident victim, San Francisco General, as per the hospital's procedures, issued a trauma alert to its staff.

Basically, that means a page was sent to doctors and anesthesiologists on call at the time. That page alone cost Palmer $4,659, and he hadn't even set foot yet inside the hospital.

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Old-school doctors

Maurice Bernstein laments the loss of the physical exam:
The old doctors had less tests and more time and more attention to the patient. Whether they could do a better job in diagnosis and treatment of the disease than more modern medicine is doubtful. But one thing is clear, they had the time to do a better history and physical and their treatment of the whole patient might be looked upon as superior.

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Zelnorm, RIP



Zelnorm has been pulled, as there is a small association with heart attacks when taking this IBS drug:
Swiss pharmaceutical maker Novartis AG will stop selling a drug to relieve constipation after it was linked to a higher chance of heart attack, stroke and worsening chest pain that can become a heart attack, federal health officials said Friday . . .

. . . Earlier this year, Novartis gave the FDA the results of 29 clinical studies of Zelnorm for treatment of a variety of gastrointestinal tract conditions. The analyses showed 13 of 11,614 patients given Zelnorm had serious and life-threatening cardiovascular side effects, while just one of the 7,031 patients given dummy pills did, the FDA and Novartis said in separate statements.

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Abortion in Mexico

Apparently access to this procedure is pretty good:
Practically, those who can scrape together $700 can get an abortion from a doctor. Some of them will even bill health insurance for the procedure, by coding it as a complication of pregnancy, according to the article.

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How to observe drug reps

John Mack goes to his doctor's office yesterday and reports on his findings.

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Single payer: The assault continues

Panda Bear just has no quit in him. The third in a series post on single payer - there's no way the American public, groomed to expect the best medical care, instantly - will stand for it:
So, it may come to pass that our country adopts a single payer system in our impossible quest to provide high quality health care for all. The result will be pretty much what anybody who thinks about it could predict. We will have a lovely little health care system that looks nice, sounds nice, and finally wins us the adulation of our charming European friends that many of us so ferverently desire. But please don’t have the bad manners, the unmitigated gall, to get sick and require anything that can’t be provided at a simple visit to your barefoot doctor. You will find your marvelous access is nothing more than a creaky rationing scheme and your shining medical city on a hill is really a Potemkin Village.
Don't miss part 1 and part 2.

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True costs of jackpot justice

An editorial in the San Francisco Examiner tells it like it is:
Next time your doctor orders lots of blood tests and MRIs, you will be experiencing a slice of the estimated $124 billion annually in unnecessary costs imposed on American health care providers through malpractice and other liability lawsuits. Doctors call it “defensive medicine” when they order lots of mostly unnecessary, time-consuming and expensive tests for fear of being sued.

Their fears are well-grounded, thanks to the legions of personal liability lawyers routinely suing doctors, hospitals, nurses, medical suppliers, drug companies and anybody else in the health care system with potentially deep pockets, often for the most tenuous of reasons.

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Capped fees for doctors

Remove the financial incentive, and you get what's happening in Canada - perceived doctor shortages:
Now, we have a situation where the great doctor can only bill a maximum of $450,000 per year (minus overhead and taxes). When, prior to the cap, he was happy to work for "services rendered" and billed accordingly.

However, now his $1.3 million practice is cropped at $450,000 per year. So he has two choices - flee to the United States, make huge dollars for 10 years, return to Canada (maybe) and be the normal doctor again. Or, look at your cap, design a perfect 40-hour week, bill out to the maximum by September of each year and then enjoy a three-month holiday.

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Coughing fit

An uncontrollable episode of coughing causes a girl to get kicked off a plane, even though a physician on board said she'd be ok to make the flight.

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Carrot or the stick?

An economist suggests demerit awards instead of performance bonuses. With all due respect to guys like Matthew and Ezra, the problem with health policy wonks is that they base their opinions with zero clinical experience in medicine. Because of this, it is difficult for physicians put any weight into anything they say.

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Elizabeth Edwards and Tony Snow: False hope?

An op-ed in the Boston Globe:
And yet Elizabeth Edwards said at a news conference, "I don't expect my life to be significantly different." She calls herself "incredibly optimistic." About his press secretary Tony Snow, President Bush said, "He is not going to let this whip him, and he's upbeat."

Of course all people need hope: hope for a good day today, hope for a normal life, and possibly hope for a cure. But that brings us to a painful and necessary question: Is there such a thing as false hope?

As a physician, I've watched more than my fair share of innocent children and adults die from cancer, often badly. It's hard to maintain optimism after that. Part of me wants to hear that not every moment with cancer can be handled with understated grace; sometimes, a primal scream would be more honest. It seems disingenuous to pretend otherwise.

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Power of placebo

Or, an IV flush for pancreatitis pain.

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Thursday, March 29, 2007

Physician's wife: "Lately, I feel like I understand Ann Coulter"

A physician is about to go through a malpractice trial. His wife goes off on a tirade:
My physician husband is going to court next week, being sued by a woman whose husband died of esophagus cancer. She thinks she deserves money because someone died. SOMEONE must pay. Win or lose, the taxpayer pays and health care costs go up for everyone. Win, and tens of thousands of dollars of malpractice insurance coverage have gone into case preparation; lose, and insurance will pay out for her "pain and suffering." Insurance companies will then raise rates for everyone, doctors and patients alike. The lawyers win either way.

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Abortion: The cost of changing your mind

A Texas senator wants to pay women $500 if they change their mind about an abortion after showing up at the clinic. Steven Levitt thinks about this:
Honestly, though, is it really such a bad idea? What if he left out the part about visiting an abortion clinic? Does it make sense to subsidize women who were going to give up babies for adoption? I think maybe it does. There are large numbers of parents who want to adopt, and a shortage of mothers willing to put healthy babies up for adoption. There are laws restricting what prospective adoptive parents can pay the birth mother. Providing a subsidy to birth mothers (perhaps conditioned on testing negative for drugs and doing a full set of prenatal hospital visits) sounds like a pretty sensible thing to do.

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Single payer ills, part 2

Panda Bear is on a roll with a follow-up missive against single-payer health care. He tries to explain it as simply as possible for those blindly support such an ill-conceived measure:
In the quasi-single payer system of Medicaid and Medicare we have today, the goverment fixes the price at such a low level that those who decide to let the dog into their practice have to run a high volume business. If the last vestige of restraint was removed from the government to at least pretend to meet a reasonable market price, the bid price for health care would fall so low that any available excess production capacity would be held back from the market in the ancient tradition of all producers in the face of price fixing, to be sold for the real price to those who can afford it. In this case this would be the same people who have health insurance now, except in a Single Payer world this would be through supplemental insurance or its functional equivalent. That is until the government that promised not to get involved in any other way but providing insurance outlaws this practice.

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The biggest hernia you'll ever see

Bard-Parker with the revealing CT scan. Wow.

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CRNA salaries

CRNAs (Certified Registered Nurse Anesthetists) make almost as much, if not more, than primary care physicians - with 2 years of college education. This post from a forum wonders how:
CRNAs make 224% as much as RNs and 156% as much as advance practice nurses (NP). According to the allnurses.com website, 58% of nurses are certificate nurses only, ie. have no advanced degree beyond a RN. It is not clear whether all these nurses were trained in 2 year certificate programs or whether some may have been trained in 18 month programs . . . Most of these CRNAs with a diploma RN and a certificate CRNA are still in practice and therefore have only 2 years of college education, period.
Some are even wondering if FPs can go back a re-train as CRNAs:
I wonder what would happen if a FP tried to apply to CRNA school. Certainly the degree they have qualifies them over a mere RN degree. Then they would go to work as a CRNA. From there it's hard not to see them lobbying to have full anesthesiologist status.

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Anti-smoking ads too disturbing for kids

Isn't that the point?

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Bribing patients to follow doctor's orders

That is the plan some are considering:
Democrats in the Minnesota state Senate want to give publicly insured patients $20 gift cards to stores such as Target as an incentive to follow their doctor's orders.

Sen. Linda Berglin, who leads the health budget panel, is betting that it will pay off for the state to sink $1 million into incentives for diabetics who control their blood sugar and smokers who quit.

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Acomplia: An uphill battle?

The once-promising pill for obesity is facing challenges in the FDA due to its psychiatric side-effects.

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Freakonomics on physician-writers

"When faced with the opportunity to read a book by someone who isn’t by profession a writer, I always go for the doctor." (via DB)

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Tony Snow's cancer: Blogosphere reaction

Orac and The Cheerful Oncologist comment further.

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Job board

The latest jobs on the Kevin, M.D. Job Board:


Together with The Health Care Blog, your job post will be viewed by readers of two prominent health care blogs, with a targeted audience of physicians, nurses, health IT, and other health professionals.

Post your job listing now.

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Wednesday, March 28, 2007

Marc Siegel apparently doesn't care about evidence-based medicine

Physicians take Dr. Siegel to task for his baseless, emotional support of CT scans for lung cancer screening. Apparently, he doesn't believe in evidence-based medicine. Money quote: "the plural of anecdote is not data."

If physicians don't believe in the evidence, how can we convince the public?
Most importantly, he also neglects to take the downside risks of screening into account: False-positives are indeed common, and the diagnostic biopsies and needless major surgeries for benign or indolent nodules are not only costly but also emotionally devastating and (in about one in 20 cases) result in severe or even fatal complications. Merely asserting that "my patients want to know if they have cancer" is not a valid way to deal with this frustrating puzzle.

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Being a woman vs being a doctor

A pediatrician's take on the breast cancer screening issue, responding to yesterday's post and today's breast screening MRI news:
As a physician, I know testing is not the be all end all, even for women. And I don't think every woman should get an MRI.

But, as a women, I can't imagine waiting 4-6 months for a retest - I'd rather the biopsy or MRI. I know - not a good use of resources and over testing just increases our out of control health care costs. But, what if...let me tell you, that what if is very, very hard to shake!
With this as the prevailing attitude to diagnosis, there is no way any type of health system where imaging studies are remotely rationed would fly. Americans like their access to tests - the concept of "false positive" doesn't resonate with the public.

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A Bill of Rights for drug reps?

One disgruntled Pfizer rep thinks so.

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Routine intraoperative cholangiograms

This is being suggested as a way to decrease the incidence of bile duct injuries - as this is one of the largest reasons for malpractice lawsuits within general surgery. I wonder if any of the surgeons who read this blog can comment:
Cholangiograms have a lot of potential, but "they have not been adopted as a routine part of most surgeons' practices," says Lawrence Way, a surgeon at the University of California San Francisco who is an expert in repairing bile-duct injuries. He says one reason for the lack of enthusiasm is that hundreds of cholangiograms would have to be performed to avoid one bile-duct injury. Some studies have suggested the cost of routine cholangiograms -- about $122 by one estimate -- doesn't justify the expected benefit.

The issue highlights a bigger debate in the medical community over the cost-effectiveness of added safety measures. Even as doctors are pressured to reduce medical errors, there is counter-pressure to cut back on unnecessary procedures and justify each expense.

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Big Pharma at the ACC meetings

The WSJ Health Blog was there, talking about the carnival-like atmosphere of the exhibit hall. Probably like Pri-Med, taken to the extreme.

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Single payer: Some common sense talk

Great post on the ills of a single-payer system. Money quote:
If you were to get in a scrap with a mean old junkyard dog and he managed to sink his teeth into your scrotum, from that point forward the dog is totally in charge. You may have the complete use of the rest of your body and even though, from a real estate point of view, the dog has laid claim to a fairly small portion of your property, where that dog goes you will go and you heart, mind, and soul will follow willingly.

Money drives medicine. Not a nurse empties a bed pan nor a surgeon repairs a hernia without money changing hands. This is so obvious that it is almost insulting to mention it. And yet the proponents of a Single Payer system seem believe that, although the government would have its teeth firmly embedded where it counts in every medical decision, nothing but good could possibly result.
(via GruntDoc)

As an aside Panda, your blog template doesn't format correctly in Mozilla. Sorry, the problem was on my end.

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Anna Nicole Smith's autopsy

Shadowfax tries to decipher what happened to her.

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"I ended up buying 60 tablets of alprazolam, just because I could"

OnThePharm takes a trip to a Nicaraguan pharmacy.

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Tort reform working in Texas

Malpractice caps in Texas are causing a problem. So many doctors want to work there, there is a certification backlog:
So many doctors are seeking licenses to practice in Texas that the board is facing a certification backlog. As Express-News business columnist David Hendricks recently detailed, the board processed 2,446 licenses in fiscal year 2001. In fiscal year 2006, the number jumped to 4,026.

More doctors who earn their medical degrees in Texas are choosing to stay here. And more doctors from other states are seeking to move here.
(via PointofLaw.com)

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MRI for breast cancer screening

Today, the ACS recommends MRI screening for women at high risk. The definition of high risk is not totally clear, and there is no mortality data on MRI screening. However, it seems there is a movement towards MRI breast screening in the general population.

This would relieve some pressure off the radiologists, since mammograms can be inclusive, leading to frequent malpractice lawsuits.

Update:
Medpundit with more.

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The smell of burning flesh

As Dr. Charles puts it, disturbingly interesting.

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Teen girls beat Glaxo

A high school experiment debunks Ribena's claim of vitamin C.

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Tuesday, March 27, 2007

Tony Snow's colon cancer has spread to his liver

The outlook is grim. Sid Schwab with more:
In the case of colon cancer which has spread to the liver, the outlook is not good. On average, survival is in the range of six months. There are exceptional circumstances, for instance when it appears than only one tumor nodule is growing in the liver, in which case removing it and giving chemotherapy may prolong life. Unfortunately that's rare: in most cases when it's discovered, it's widespread.

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UnitedHealth: Please insert foot in mouth

Stanley Feld summarizes how UnitedHealth is one of the big problems in our health care system today.

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Top counterfeited medications

Many of them are used to treat HIV. Sad.

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How to cross-examine an attractive doctor

Lawyers, worried about the recent study suggesting how attractive people can sway juries? What if the physician-defendant you're cross-examining is too attractive for your liking?

No fear, here's how to overcome this.

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The sad plight of William Hurwitz

In the DEA's fight against chronic pain treatment, patients are often the losers:
“Doctors are trained to treat patients, not to be detectives,” says Dr. James N. Campbell, a Johns Hopkins University neurosurgeon specializing in pain, who will be another witness for Dr. Hurwitz. He says that doctors have already reacted to the D.E.A. crackdown by changing the way they deal with the many Americans — at least 50 million, by several estimates — who suffer from chronic pain.

“Opioids were a revolution in pain treatment during the 1990s, but doctors are now more reluctant to use them,” Dr. Campbell says. “If a doctor perceives there’s a 1 in 5,000 chance that a prescription will lead to a D.E.A. inquiry — just an inquiry, not even an arrest — he’s not going to take the chance. So the victims are the patients.”

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Why "wait and see" doesn't fly with the American public

A story from the Washington Post about the ambiguity of mammogram readings. "Wait and see", or the conservative, evidence-based approach, clearly is taking a hit in this piece. A breast MRI to confirm an ultimately harmless finding is demanded by the patient.

Essays like this, which perpetuate the falsehood that more testing equals better medicine, simply serve to further drive up health care costs. (via The WSJ Health Blog)

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Neurosurgeon turned spa doctor

Vision problems forced the career change - but his malpractice history, and Google, is scaring off potential spa clients.

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Grand rounds is up

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

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Stents and the COURAGE trial

Cardiologist Dr. Wes looks at the real-world implications. Bob Centor also chimes in. Here's what the NEJM thinks.

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Add Massachusetts as a physician-shortage state

Combine high cost of living with this, and no wonder they're having trouble recruiting:
Massachusetts continues to decline as a place to practice medicine, the Massachusetts Medical Society reports today. The deteriorating environment has led to a shortage of physicians and reduced access to care that are a cause for concern as the state implements its new healthcare law, the group warns. . .

. . . Low reimbursements for services, administrative hurdles such as pre-authorizations for imaging tests and prescription drugs, and increasing costs of operating a practice were cited as problems local doctors face.

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