Kevin, M.D. - Medical Weblog

Appendectomy via the mouth

First, a cholecystectomy via the vagina, now surgeons are looking at the other end:

Transgastric surgery, or natural orifice translumenal endosurgery (NOTES), as it is officially known, involves passing flexible surgical tools and a camera in through the patient's mouth to reach the abdominal cavity via an incision made in the stomach lining. Once the operation is over, the surgeon draws any removed tissue back out through the patient's mouth and stitches up the hole in the stomach.

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Googling your adversary

Flea Googles the plaintiff's lawyer in his upcoming trial and this is what he found.

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Aging

Atul Gawande on aging and the fate of the elderly:

Despite a rapidly growing elderly population, the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don’t like taking care of the elderly . . .

. . . On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk or closed their geriatrics units. Several of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.

(via kottke)

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Maine's universal health plan a failure

Not mandating people to buy insurance was their mortal downfall:

And while some people have benefited from the subsidized insurance, which provides unusually comprehensive coverage, others have found it too expensive. And premiums have increased, not become more affordable, because some of those who signed up needed significant medical care, and there are not enough enrollees, especially healthy people unlikely to use many benefits.

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The next malpractice burden: Payouts for grief

More ways for lawyers to make money?

The flashpoint is a proposal that would allow family members of someone who has died to seek damages specifically for "grief, sorrow and mental anguish" — in addition to other economic and noneconomic damages — in any wrongful death lawsuit. The bill goes to the state Senate this week; it passed the House on Friday with nearly all Democrats in support and all Republicans in opposition.

Trial attorneys say the changes to Illinois civil justice codes would provide compensation for what amounts to heartache. But the idea has angered businesses and in particular doctors and hospital administrators who say it's just another way for lawyers to seek money.

The measure would cover all wrongful-death cases — drunken driving crashes or on-the-job accidents, for example — but it also would apply to medical malpractice, always a hot-button issue.

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Declining reimbursements and you

How inappropriate reimbursement is affecting Vermont:

For years, Medicaid's rates haven't covered the cost of the care (not the prices, but the actual cost of providing care) provided to Vermont's Medicaid beneficiaries. Recently, Medicaid rates to most providers have been cut dramatically or have not included even inflationary increases.

The consequences of these chronic underpayments are being seen today -- higher premium prices, not enough doctors and dentists, and access problems for nursing home care. When Medicaid underpays physicians and dentists, the ultimate consequence is that they leave the state or close their practice to Medicaid beneficiaries because they can't afford to build a practice based on Medicaid patients at current payment rates. Underpayments also cause nursing homes to close or stop taking Medicaid patients, like Genesis nursing home did when they closed in Morrisville three months ago.

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Job board

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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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New Orleans: "It's a dangerous place to live for unhealthy people"

Healthcare workers are not returning at the same pace as the residents:

Residents are returning to New Orleans faster than healthcare workers. The shortage of doctors — on top of fewer and overcrowded hospitals, lost or destroyed medical records, and delays in everything from getting an appointment to lab test results — has contributed to a sense that medical care here is still not recovering.

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Fixing doctor rating sites

This sounds promising:

. . . some very good efforts (honestly) have been made by ratemds.com and vimo and even Yelp. The problem is that these ratings are typically based upon a single instance of a person who purposely decides to go find their doc info and then rate THAT physician… once. They rarely, if ever, go back and update their rating or follow-up experience.

Well, we’re going to take a different spin at it, because what consumers are used to seeing via amazon.com and other user-generated ratings are the TRENDS of other peoples feedback. I rarely buy a book or service based upon ONE opinion or review… I look at the list of reviews and see if there is a consistency or trend.

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Medical wikis

AMNews with an article today:

As more medical wikis launch, experts say the creators will need to break away from the traditional wiki model to ensure that the information accessed is accurate. That is what many medical wikis are doing, which makes adding content slower but allows time for fact-checking.

Isn't that defeating the purpose?

David Rothman also has more on this article.

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Dealing with consultants 101

Written from an ER perspective, some of these tips come in handy when you're also calling specialists from the medicine floor.

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Hurwitz verdict: "The jurors were confused by the law"

Pain management suffers a setback when physician William Hurwitz was convicted. John Tierney looks at the verdict:

I can’t blame the jurors for being confused, because that’s the norm in trials of pain-management doctors. The standard prosecution strategy is to charge the doctor on so many counts and introduce so much evidence that the jurors assume something criminal must have happened. Their natural impulse, after listening to weeks of arguments, is to look for a compromise by digging into the mountain of medical minutiae – and getting in so deep that they lose sight of the big picture.

(via Overlawyered)

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"The international language of Viagra"

Only shown in Canada, I saw this TV spot a few times last week when I was in Toronto. It was a gibberish ad that didn't make sense at the time. Now, the NY Times with an explanation:

Pfizer, the world’s largest drug company, offers an answer in a new campaign for Viagra, so far shown only in Canada. The ads feature middle-aged men and women talking in a made-up language, save for one word.

“Viagra spanglecheff?” says a man to a friend at a bowling alley.

“Spanglecheff?” his friend asks.

“Minky Viagra noni noni boo-boo plats!” the first man replies, with a grin that suggests he is not talking about the drug’s side effects. The ads end with the slogan, “The International Language of Viagra.”

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Do non-English speakers cost practices money?

Yes, according to a survey, to the tune of $19,000 annually.

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Laceration porn

Courtesy of Shadowfax and Scalpel.

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Gourmand syndrome

I think I may have this newly discovered neurological disorder:

We present a new benign eating disorder associated with lesions involving parts of the right anterior cerebral hemisphere. This "gourmand" syndrome describes a preoccupation with food and a preference for fine eating.

There is a blog dedicated to this as well. (via Medpundit)

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Personal liberty vs mental health detention

GruntDoc on why the Virginia Tech shootings can happen again:

Here in Texas, there’s a great emphasis on personal liberty (“It’s not against the law to be crazy”), and that’s good the vast majority of the time. There is indeed an emergency mental health code for the psychotic, deranged and suicidal, and it’s not easy to utilize. There is no simple form, but a multipage affidavit that has to be signed by a judge prior to holding a patient for involuntary psychiatric evaluation, and that’s assuming you can get an officer to initiate the form in the first place (mere physicians cannot). For a police officer to begin the paperwork, the patient must be in imminent danger of harm to self or others due to mental illness.

And, there’s the rub. As the patient is in an ED, the cops tell us ‘they’re not in imminent danger, as they’re here in the ED’, and they refuse to initiate a hold . . . they’re just not going to even try.

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Hospitalists: Good in theory

Aggravated DocSurg talks about how his hospitalist program is too disorganized, leaving many peri-operative complications to the surgeon.

In theory, hospitalist programs should be well-staffed, and internists available for consults. The reality is that many of these programs are in their infancy, and recruitment to smaller community hospitals are a problem. Combined with the high turnover rate inherent in this specialty, many programs are in a state of constant flux.

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Dr. 90210

A busy practice and successful TV show. How responsible is he for the plastic surgery boom? ABC News does a profile.

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Google yourself: Tips for your search engine reputation

Recent stories have highlighted the importance of your Google reputation. There is no doubt that patients and potential employers will Google you as an initial screen. It is to your benefit to ensure that favorable stories come up when your name is entered as a search term.

Here are some basic tips to help take control of your name's Google search.

Start a blog
A double-edged sword. Of course, there are some who blog anonymously, and don't want their name associated with their blog. However, Google places an emphasis in their search rankings on regularly updated blogs. Starting a blog associated with your name is an easy way to take control for your name's Google search. For instance, this blog comes up as the first search result when my name is Googled.

Keywords in blog entry titles
Similarly, Google places emphasis on the titles of blog entries. If you want to be associated with specific topics, try incorporating keywords into the titles of the blog entry. In Blogger, the title is incorporated in the file name of the page, which also helps with the search engine rankings. Of course, this would stifle some creative titles, but if you're serious about increasing Google exposure, it's a trade-off.

For instance, this blog is found on the first page for Google searches on recently discussed topics like defensive medicine, Anna Pou, Michael Moore's Sicko, COURAGE trial, and Elizabeth Edwards breast cancer.

Get blogged
It may be difficult to be mentioned in a publication. If you have that opportunity, it can only help. However, it is much easier to be interviewed on a blog or have a blog write about you. For instance, Dr. Brent James, a patient safety advocate, was interviewed by Matthew Holt on his blog. A Google search for "Brent James" finds that interview on the second page of search results.

Ves Dimov at Clinical Cases had this article written about him, which shows up prominently when his name is Googled.

A corollary of this tip is beware who you piss off. Although it is easy for bloggers to build up your Google reputation on a search page, they can just as easily bring it down. A negative blog post written about you by prominent bloggers will also show up high on your Google name search.

Optimize your blog template
A more advanced tip. If you run a blog, you owe it to yourself to have a template that is search engine friendly. There are many sites that give tips to optimizing your page for SEO. However, if you are serious about maximizing your Google exposure, I suggest having a professional rewrite your template with that goal in mind. I recommend the folks over at Blogging Expertise.

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Single-payer bias

A recent study comparing American and Canadian health care systems is tainted by the bias of its authors.

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Going over the tapes

Sports players and coaches aren't the only ones who studies film. This ophthalmology resident does the same after his cataract surgeries.

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A rare ER case

Charity Doc with the latest case from his ER:

Single GSW with entrance wound to the left flank, no exit, was all the injury that the guy had on full body exposure and log-rolling.

"Got your chest xray and KUB up!" announced the xray tech.

"Whar's the bullit?!" I kept on asking out loud after seeing both unremarkable xrays. "Whar's the bullit, whar's the bullit...No exit wound...Whar's the bullit?"

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An ER doc tells off drug seekers

An anonymous rant found on craigslist:

The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting by you might not be lying

(via Type-B Premed)

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How Doctors Think

I am happy to introduce How Doctors Think and publisher Houghton Mifflin as the newest sponsor to Kevin, M.D. I recently finished reading Dr. Groopman's book and this should be required reading for any health care provider today.

Description

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-Ron Chernow, author of Alexander Hamilton, Titan, and The House of Morgan

"A cogent analysis of all the wrong ways his fellow practitioners are trained to approach the patients they treat.”
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Sponsorship opportunities continue to be available. This can be via a Premium Blogad, Standard Blogad, or a customized package.

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Arcoxia: Denied

It's official.

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"Allergic to modern living" part 2

Another one is taking precautions against . . . well pretty much most modern communication devices. She's not the first:

Sarah, 51, is one of a growing band of people who claim to be experiencing extreme - and incapacitating - sensitivity to electrical appliances, as well as to certain frequencies of electromagnetic waves.

"Wi-Fi, or wireless broadband networks, seem to be the worst thing," she says.

"Closely followed by mobile phones - particularly if they're being used in an enclosed space - the base stations of cordless telephones and mobile phone masts.

"I have to restrict the amount of time I spend on the computer or watching television, and make sure I don't have too many household appliances on at once, because that sets me off as well."

This may sound bizarre, but there is no doubt that Sarah's symptoms are real.

To date, they include hair loss, sickness, high blood-pressure, digestive and memory problems, severe headaches and dizziness.

They strike with such ferocity that, since diagnosing herself as "electrically sensitive" in May 2005, she has been marooned at home.

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Midwife malpractice loss: "I hope she learned her lesson"

A nurse midwife failed to call for physician backup after a non-reassuring fetal tracing.

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How to explain defensive medicine to a patient

The question should be rephrased to "How close to 100% certain do you want to be?" As I stated before, if a patient understands the risks of an unnecessary test to get closer to the impossible goal of 100% accuracy and chooses to proceed, I normally would then order the test.

Scalpel with an example regarding chest pain in the ER.

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Med School in a Box

4-years of medical training condensed in 96 pages. Considerably cheaper than tuition too. (via White Coat Notes)

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Second Life and medicine

ScienceRoll points to the use of medicine in "virtual worlds" like Second Life, which is kind of like the world found The Matrix. Here's a Second Life scenario teaching cardiac murmurs:



Just a game you say? Well the American Cancer Society and CDC are early adopters by setting up presences in this online world.

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Shrek fired

Apparently he wasn't promoting a healthy-enough lifestyle in his movies. (via Medpundit)

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Medblogs in the Annals of Emergency Medicine

A recent article highlights the prominent emergency medicine bloggers. (via Graham)

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Are our physician leaders out of touch?

Dr. Rob thinks so:

I think that this is a fundamental problem in our system. For policy makers to understand what is wrong with the system, they must be able to hear it from those most affected by the deficiencies in the system. The problem is that those people who are in the most distress are exactly those who cannot afford to take the time to put forth their voice. In general, the “physicians” who populate the committees, task forces, and advisory panels are at best only practicing part-time. A friend of mine (who works in DC) says that often physicians on these panels introduce themselves as “recovering physicians,” with a chortle from the committee in response.

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Single payer = physician shortages

More evidence from Canada:

If you believe such shortages can’t happen in the United States, think again. Medicare already presides over a Byzantine system of price controls that it is planning to expand. This system has already created primary care shortages in many rural areas in this country, and its planned expansion will create more.

If the voters are foolish enough to bestow the presidency on a proponent of “single-payer” health care in 2008, a shortage of physicians is just one of the hardships they will receive for their trouble.

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Doctors should Google themselves

As the world becomes indexed via search engines like Google, online reputation becomes important - especially for health care providers. Patients are likely going to Google you as a quick screen, whether you like it or not:

With so much information accessible just by entering your name, the name of someone you know, the name of a business associate or even the name of a patient into a search engine, any pretense of manners or decorum has long been chucked out the window when it comes to digging for dirt, or lack thereof. In fact, far from being seen as rude, self-searching in particular is considered a wise business strategy, a way to make sure you know what face you are portraying to your patients -- and your potential patients.

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Malpractice juries

Flea continues prepping for his trial and reveals that the facts of the case barely matters:

A jury's decision-making process depends more on the doctor's character, or what they perceive the doctor's character to be, than on the medical facts of the case. The break-down was astonishing: Doctor's character accounts for 97% of a jury's decision, the medical facts of the case, 3%.

Did y'all get that? The facts of the case amount to roughly squat. What really matters is the impression Flea will make on the jury.

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Patient blogs: A HIPAA nightmare?

Dr. Wes on the rise of patient blogs and what it means for HIPAA:

Patient blogs are now the rage at local hospitals here in Chicago, detailing play-by-play accounts of health care delivery and histories on patients themselves. You see, patients aren't covered by HIPAA. They can say what ever they want about themselves. But sometimes the patient isn't the one posting on the patient's blog, family members were, dutifully updating the daily progress of their loved one to the world . . .

. . . So in the future, if doctors or insurers get accused of violating the HIPAA provisions, they'll just look stupid and say, "Hey, I just read what I know about him on his patient blog!"

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The four-hour pneumonia window "fix"

JCAHO takes the easy way out, and expands the antibiotic-pneumonia window to six hours. retired doc is not impressed:

Reacting to an outpouring of criticism and valid complaints about the simplistic four hour pneumonia rule the Joint Commission (aka JCAHO) emphatically demonstrated that they did not get the point and moved to correct the problem by increasing the time to six hours. They also amended the original rule by adding a diagnostic category called "diagnostic uncertainty", cases designated as such would not be included in the emergency department report card.

Predictably, some advocates of the rule complained that this category will set the stage for cheating.If the six hour clock has run out,those devious ER docs can place the case in that category.You just can't trust doctors, you have to watch them all the time.

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Hospitals: "Even a dose of last century’s computer technology could go a long way toward cutting waste"

Many hospitals and doctor's offices are still pushing paper from room to room.

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Screening embryos for breast cancer

A slippery slope?

Until recently, the screening - called pre-implantation genetic diagnosis (PGD) - was approved only for genes that always cause diseases when inherited, such as in cystic fibrosis . . .

. . . Last May, the watchdog ruled it acceptable for doctors to screen embryos for genes such as BRCA1, which raise the risk of cancer in adulthood by 60-80%.

However, it still has to approve each application on a "case by case" basis - something these couples are still waiting for.

Critics say if the HFEA does give the go ahead it is a continued journey down a slippery slope to "designer babies". There is concern that in the future embryos could be screened for non-lethal and even trivial conditions.

Also, the procedure means that affected embryos are created and then destroyed.

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Abortion ship

A ship will take women out to international waters to perform abortions.

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Dr. John Corso: Another physician ignoring the evidence

Another member of mainstream media takes an evidence-bereft, pro-screening bias. This time, electron beam CTs for coronary artery disease, a AAA screening test for adults age 40 and above (contrast with the USPSTF recommendations), hi-res chest CT for lung cancer, and a PillCam screen for esophageal cancer are the "routine" tests recommended by Dr. Corso.

I'm ashamed to say this is an internist recommending these tests, ignoring the evidence. He's trying the hawk his book, and as I said before, the evidence doesn't sell.

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Peter Rost twists the knife in AstraZeneca

He publishes secret training tapes, and mainstream media is throwing oil on the fire.

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Chicago Sun-Times gets prostate cancer screening wrong

Schwitzer with another instance of the media's non-critical pro-screening bias. This time, the Chicago Sun-Times with another irresponsible article on prostate cancer screening. I guess the evidence doesn't sell papers.

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Prepping for a malpractice trial

Flea tells us about how he is training to be prepped by a hostile attorney:

Flea will probably be the plaintiff's first witness. He was instructed to angle his chair slightly toward the jury, and to keep his claws folded in his lap. He was instructed to turn his head toward the plaintiff's attorney while answering questions, then to turn to face the jury and answer slowly, separating words, and loudly enough for the farthest juror to hear. Answers should be kept to no more than three sentences.

(via White Coat Notes)

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Most physicians report ties with Big Pharma

And this is supposed to be news?

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Job post: Policy A