Kevin, M.D. - Medical Weblog

How to stick it to unhelpful consultants

An ER doc strikes back.

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Who’s the patient?

Getting hooked at WhiteCoat Rants. Worth a chuckle.

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Don't alter prescriptions

Especially if you have Parkinson's.

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Medgadget vs Sermo

Turning up the heat?

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Neurosurgeon: "People think we make millions of dollars, but that’s not true"

More on critical physician shortages due in part to rising malpractice rates.

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Pelvic exams in the ER

How useful are they really?

For such a useless procedure, there is an unreasonable amount of emphasis placed on its performance by our consultants, probably a vestigial remnant from the olden days when CT scans, ultrasounds, and antibiotics were not as powerful or widely available.

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A typical ER shift

You'd be surprised at how little time is spent on actual medical emergencies.

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The 5-hour CT scan

A woman was forgotten in a CT scanner. Scary thing is, this wasn't the first time this happened:

A physician who works at the practice and knew of the incident said it's not the first time such a thing has happened. "People have been left in the office after hours, when something like that happens — it's the same sort of thing," said Dr. Steven Ketchel. "My guess is she was lying on the table, waiting and waiting and nobody told her she could go home."

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Leaving your mark

Sid Schwab on naming anatomy:

When it takes some effort -- maybe a microscope or some really careful dissection -- to discover something, it seems reasonable that your name gets attached. Islets of Langerhans. Ampulla of Vater. Sphincter of Oddi. Valves of Heister. Crypts of Morgani (he got "columns," too.) But where's the cutoff? I don't get why Gabriele Falloppio got to name something as obvious and macroscopic as an oviduct. That's not discovering. That's noticing. We don't have the Colon of Powell, or the Heart of Palm.

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Cover your ass, defensive medicine

Chris Rangel on how defensive medicine has changed the practice of medicine:

The practice of emergency medicine (among other high risk specialties) has become so regimented and infused with defensive medicine tactics that many ER docs are not even aware of how this has changed the way they think. It seemed as if this ER physician could not fathom the concept that we would send home a patient who could easily have just had a heart attack despite the fact that we were going to do absolutely nothing different for her then if she went home. Even though the possibility of litigation in this case was remote it was the constant and overall threat of litigation that has fundamentally changed the thinking of physicians and how they practice medicine.

This change in thinking has had significant consequences. Ever wonder why we spend so much on medical care? Part of the answer lies in this example. This ER doc was about to turn an $800 ER visit into a $4,000 hospital admission. Now imagine this happening all over the country in multiple variations and degrees of absurdity tens of thousands of times EVERY DAY.

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MedBlog Power 8

9/26/2007-10/03/2007
Next revision: 10/03/2007



(Key: Rank, Blog name, Last week's rank, Post of note)

1) Surgeonsblog (2), Pattern Recognition

2) Musings of a Distractable Mind (3), American Medicine: Information is Power

3) Shrink Rap (6), How A Shrink Picks An Anti-Depressant

4) WhiteCoat Rants (1), The Medicaid Ripoff

5) Medgadget (-), Confirmed: Sermo Is Not for Physicians Only; New Important Questions Raised

6) Panda Bear, M.D. (-), Emergency Medicine Residency (Part 1)

7) Dr. Wes (-), Lost in Transition

8) The Physician Executive (-), Time Spent in Clinic

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised every Wednesday and will be published every 2-3 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

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MedPage Today

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Physicians and other healthcare professionals can accrue CME simply by reading the news. Articles are accompanied by a CME Post-Test, where AMA PRA Category 1 Credits can be obtained, without a fee. Not a bad deal.



Read more about MedPage Today.

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Job board

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Chantix: Pfizer's golden goose?

With the miserable failures of Exubera and torcetrapib, Pfizer is throwing some marketing muscle behind Chantix - an anti-smoking medication that actually works and is quite useful. A look at the recent DTC ad for the product.

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"I order a lot of CT scans"

An ER doc confesses:

I shouldn’t let this kind of thing bother me. Why should I care what the techs and nurses think? Let them walk a mile in my shoes. They’re not held accountable if they miss a head bleed or PE or small bowel obstruction or neck fracture. I am.

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A for-profit DO school is about to open

Bizarre and could be start of a disturbing trend. What kind of corners will be cut in the name of profit?

Critics say a for-profit school will be beholden to investors and will scrimp on educational mission. Supporters assert that Rocky Vista must meet the same accreditation standards of other osteopathic schools. They also say the school's educational outcomes will be the same as nonprofit schools.

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Lab tech gone wild

A lab tech bites a 3-year old boy while trying to draw blood:

A former lab technician admitted to investigators she bit an autistic boy during a blood test, saying the 3-year-old had bitten her first, Indianapolis police said Wednesday.

The Gone Wild series continues.

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Mmm . . . purple urine

What a fascinating cause of this phenomenon:

Purple discoloration can occur in alkaline urine as a result of the degradation of indoxyl sulfate (indican), a metabolite of dietary tryptophan, into indigo (which is blue) and indirubin (which is red) by bacteria such as Providencia stuartii, Klebsiella pneumoniae, P. aeruginosa, Escherichia coli, and enterococcus species.

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The patient-hitting cardiologist

He has resigned from the hospital, but gives his side of the story:

He said the patient was “a drug addict coming off of opiates, completely in withdrawal (and was) restrained as he should have been by protocol by five technicians. I was only the sixth person, never hitting anybody.”

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Why does American medicine do so many tests?

Megan McArdle wonders:

You can't blame it all on lawsuits; my doctor didn't test me for hyperthyroidism because she was afraid of the malpractice suit that would result from my losing too much weight and getting heart palpitations. Nor can you blame it on money; my doctor doesn't profit from giving me blood tests that all come back normal. And I don't think the lack of rational rationing can be the culprit either. To the extent that insurance companies have bad incentives, it should be to do too little, not too much. They should have incentives to ration this sort of thing, but they don't.

I suspect the ultimate cause is the medical culture, which will make this sort of thing very hard to eradicate in either a single-payer or a private system.

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Malpractice: Fight or settle?

This physician was pressured to settle, to his regret:

I spoke to some of my senior colleagues and they all advised me to settle. I relented, and what followed was a nightmare of the worst kind.

My insurance carrier increased my premium from $4,000 to $30,000, terminated my liability coverage, and then cornered me to buy a tail for $30,000 or retire. With retirement as no option, I found inflated liability coverage from the secondary market for $30,000 each year since the settlement.

I found that I became unemployable. No one returned my calls after job applications. My friends and colleagues avoided me, knowing that I would ask them about employment situations. The hospital where I was trained suggested I try elsewhere for a nonclinical position. In the meantime, I had to write to the state regulatory body to keep my license and avoid disciplinary action, including losing my license to practice.

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Specialist shortages in the emergency room

One of the best medical blog writers is ED physician Edwin Leap. With all the talk about emergency room specialist shortages, he implores his specialist-colleagues to step up to the plate:

And here’s one last reality. This is America. It isn’t the Communist block with bizarre borders and border guards. If a patient needs your care, but isn’t from you community, why does it matter? I’d keep them if I could, but I can’t, so help me out! I know you may have financial incentives, or you may be overwhelmed already, but I’m not sending them by the bus-load, only rarely, and one at a time. And only when I can’t do it myself.

Attention Doctors…step up to the plate! Let’s be the professionals, heal the sick, treat the wounded, comfort the dying. The money will come, I promise, if we act like the heroes we can be, the heroes we should be. Let’s reclaim medicine! But we can only do it if we take care of those ‘pesky sick people.’ After all, they need us.

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Talking Health 2.0

Joshua Schwimmer gives a talk on the subject. Thanks for the mention!

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"Why aren't administrators more concerned with cleanliness?"

Can it be because of the money?

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A health insurer positive on Hillary Clinton?

Harvard Pilgrim CEO Charlie Baker with a positive take on one of Hillary's ideas.

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How to piss off your EMT

A list of surefire ways. (via Scalpel)

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EDs and the stronger toilets

Emergency care of the obese is stressing out the system:

"The major burden on the emergency system is on prehospital care," said Dr. Jay Goldman, national medical director of Ambulance Services/EMS for Kaiser Permanente in California. "Extricating these patients from crashes takes longer, is more difficult, and moving them from their homes to the ambulance, down three flights of stairs, is dangerous to providers."

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MedBlog Power 8

9/26/2007-10/03/2007
Next revision: 10/03/2007



(Key: Rank, Blog name, Last week's rank, Post of note)

1) Surgeonsblog (2), Pattern Recognition

2) Musings of a Distractable Mind (3), American Medicine: Information is Power

3) Shrink Rap (6), How A Shrink Picks An Anti-Depressant

4) WhiteCoat Rants (1), The Medicaid Ripoff

5) Medgadget (-), Confirmed: Sermo Is Not for Physicians Only; New Important Questions Raised

6) Panda Bear, M.D. (-), Emergency Medicine Residency (Part 1)

7) Dr. Wes (-), Lost in Transition

8) The Physician Executive (-), Time Spent in Clinic

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised every Wednesday and will be published every 2-3 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

Posted by Kevin | link | Comments (0) |

Sophie Currier wins her appeal

Surprising. The breast-feeding mother who sued the NBME for extra time during her board exams finally gets a decision in her favor. The squeaky wheel really does get the oil:

A Superior Court judge last week rejected Currier's request to order the board to give her an additional 60 minutes of break time. Appeals Court Judge Gary Katzmann overturned that ruling, finding that Currier needs the extra break time to put her on "equal footing'' with the men and non-lactating women who take the exam.

The medical community response doesn't seem to support her at all.

Update:
Neither does the public at large, judging from the comments here and here.

Posted by Kevin | link | Comments (24) |

Woman delivers baby in 8 minutes

Serving curry one minute, a baby born in another seven.

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Europe banning MRIs?

It could happen as early as 2008:

Implementation of the Physical Agents (Electromagnetic Fields) Directive 2004/40/EC in all Member States could effectively halt the use of magnetic resonance imaging (MRI), an important tool in cancer diagnosis, treatment, and research, a scientist told a press conference at the European Cancer Conference (ECCO 14).

The Directive is due to be implemented across Europe by April 2008.

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Medgadget keeps the pressure on Sermo

With an open letter to their CEO regarding recent security concerns. A situation all emerging health 2.0 sites should monitor.

Update:
Sermo with a response.

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When you're wrong about child abuse

Accusing parents of child abuse is serious business:

"It's a very agonizing decision," he says. "I have to be 100 percent correct, because if I diagnose a child as abused and it's not, it's as damaging to the child and the family as if I return a child to an abusive environment. The ramifications of my diagnosis are huge."

Unfortunately, Steiner has been wrong -- on more than one occasion.

Posted by Kevin | link | Comments (10) |

Government-run health care

Why an NHS-style system is not realistic here in the United States:

The British are often held up as the standard to which we should aspire. But we don't live under a British style of government. We live under a government that's truly government of the people, by the people, for the people. And what the people want, the people get . . . In England, the government only pays for colonoscopies to check for colon cancer if there are symptoms suggestive of cancer or a family history of colon cancer. In the United States, the Medicare pays for a colonoscopy every ten years for everyone over 50, regardless of symptoms or risk . . .In England, mammograms are only covered for women between the ages of 50 and 70, and then only every three years. In the United States, we pay for mammograms beginning at age 40, yearly, and with no upper age limit. We just don't have the heart for rationing that they have in other countries.

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Democrats' health plans

Of course it's a back door to a single-payer system.

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Expert witness pleads guilty

A cardiac surgeon is forced to retire after falsifying his expertise as a witness. (via Overlawyered)

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UK: What Sicko doesn't tell you

A look at the movie from an NHS perspective:

Viewers of Michael Moore's new film will come away convinced that the public healthcare system in this country is superior to its privatised American counterpart, where more than 50 million people are without any kind of care at all. But does the government agree? Or has it instead been taking ideas from the very system revealed in Sicko to be so iniquitous?

(via The Medical Quack)

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MedBlog Power 8

9/26/2007-10/03/2007
Next revision: 10/03/2007



(Key: Rank, Blog name, Last week's rank, Post of note)

1) Surgeonsblog (2), Pattern Recognition

2) Musings of a Distractable Mind (3), American Medicine: Information is Power

3) Shrink Rap (6), How A Shrink Picks An Anti-Depressant

4) WhiteCoat Rants (1), The Medicaid Ripoff

5) Medgadget (-), Confirmed: Sermo Is Not for Physicians Only; New Important Questions Raised

6) Panda Bear, M.D. (-), Emergency Medicine Residency (Part 1)

7) Dr. Wes (-), Lost in Transition

8) The Physician Executive (-), Time Spent in Clinic

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised every Wednesday and will be published every 2-3 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

Posted by Kevin | link | Comments (1) |

iMedExchange

I would like to thank iMedExchange for their continuing Premium Sponsorship at Kevin M.D.

Focused on physician care, iMedExchange improves the work and well-being of physicians by connecting and supporting them in a productivity-based and opportunity-rich online environment. iMedExchange is being built by a team of business, technology, and healthcare experts who are building the most useful online place for physicians. They are looking for doctors to joint their Consultant Network, and contribute to this physician-focused company.

"Physicians today are highly challenged, and we need help managing our personal lives, practices and patients. iMedExchange is addressing these needs head-on. I joined the iMedExchange Consultant Network (iCN), and became one of the many physician investors in order to be a part of this powerful solution for physicians." R. Maoud, M.D. (Internist, iCN Member, Physician Investor)

You can meet Dr. Patel and Dr. Stanley, their 2 'spokespeople' at www.iMedExchange.com to learn more about iMedExchange, and their Consultant Network.

Sponsorship opportunities continue to be available. This can be via a Standard Blogad or a customized package. Please visit the advertising information page for further details.

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Pre-rounds on Medscape

Here is Medscape's Pre-Rounds piece that normally accompanies Grand Rounds. Thanks again to Nick Genes.

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"Do I really need that?"

A simple question can greatly impact health care costs:

Millions of such conversations would be useful, given the tremendous amount of wasted care in American medicine. Patients get tests and treatments they really do not need because they don’t know better (resulting in antibiotics for viral colds, for example), because our physicians are paranoid about being sued (resulting in defensive X-rays and other tests), and because many physicians and patients ignore guidelines suggesting when some tests and treatments can be avoided.

Money is another key reason for unnecessary tests and treatments. The majority of patients do not pay for all of their health care, providing them some protection from the financial ramifications of unnecessary tests and treatments. Why shouldn’t I have an ankle X-ray just to be sure I don’t have a tiny fracture if it doesn’t cost me anything? Perhaps as important, no one providing health care gets any revenue when a test or treatment does not get done, which means the business model of health care benefits from all testing and treatments, regardless of the benefit to the patient.

Fear also plays a role. If a test or treatment is not done, the patient may be unhappy or be harmed by a missed diagnosis, and the physician might get sued. By comparison, a test or treatment that costs money but seems unlikely to cause harm is a small price to pay.

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The annual physical

There never has been any data to support its use. The latest attack comes from the Archives of Internal Medicine:

The discussion about whether an adult needs an annual physical has been ongoing for nearly a century, Mehrotra tells WebMD. Currently, no major North American health-related organizations recommend the routine annual exams, he says.

Still, many patients as well as many doctors believe the annual visits are a medical necessity. "The vast majority of people think they are being good patients if they go in to see their doctor every year," says Mehrotra. "Most doctors actually believe the same thing."

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John Edwards calls reducing medical malpractice lawsuits a "good idea"

He supports "certificates of merit" before filing medical malpractice lawsuits:

Democratic presidential candidate John Edwards, who made his fortune as a trial lawyer, says attorneys should have to show their medical malpractice cases have merit before filing them.

He also said attorneys with a history of frivolous suits should be barred from filing new cases.

Posted by Kevin | link | Comments (3) |

A prominent surgeon goes on trial

What it's like for a physician to be sued for malpractice, and the experience behind the subsequent trial.

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Walk-in clinics and patient satisfaction

A Canadian study suggests that patients were less satisfied with walk-in clinics. Something to mull over as retain clinics begin to take hold Stateside.

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The 24/7 doctor: Old-school vs new-school

Two doctors offer differing styles of 24/7 coverage. Established physician Ben Brewer and young gun Jay Parkinson.

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Does the nose get the shaft?

Dr. Rob pays it proper respect.

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UMDNJ: Doctored grades

As if they didn't have enough problems already:

Paul Mehne was a popular dean on the Camden campus of the state’s medical school, well-liked by the small cadre of students there who felt their satellite program in South Jersey was something special.

What troubled investigators, however, is that none of his students ever seemed to fail. A new report by a federal monitor, scheduled to be released tomorrow, concludes that Mehne doctored the grades of several medical school students, including some now practicing medicine, giving passing test scores to those who came up short on exams needed to begin specialty rotations.

(via Health Care Renewal)

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Work notes: "Can't anyone suck it up anymore?"

What pushed a normally calm physician over the edge.

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NHS: "Rationing is the great unspoken reality"

Tell me something I didn't know:

Doctor magazine asked readers about rationing. Of 653 answering questions on consequences, 107 - 16% - said patients had died early as a result.

More than half - 349 - said patients had suffered as a result. This compared with one in five in a similar survey conducted nine years ago.

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