Thursday, January 31, 2008

Military medical malpractice



CBS News with a piece wondering if military and VA physicians should continue to be protected from medical malpractice under the Feres Doctrine.

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MedBlog Power 8

01/30/2008 - 02/07/2008
Next revision: 02/07/2008



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

1) The Happy Hospitalist (2), What Would You Recommend?

2) Respectful Insolence (-), Irresponsible anti-vaccination idiocy about autism to air on ABC's "Eli Stone"

3) Health Beat (1), The Prostate as Crystal Ball

4) WhiteCoat Rants (3), Placebo Power

5) Running a hospital (-), On advertising

6) Panda Bear, MD (-), Chicken Soup For the Emergency Medicine Resident’s Soul: Inspiring Stories From the Emergency Room

7) Dr. Wes (5), In-ies or Out-ies

8) ER Stories (4), Medical Sayings, Abbreviations and Acronyms Part 2

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 mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

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Was Glaxo tipped off to the Nissen crusade?

The GSK mole: "Why I sent it is a mystery. I don't really understand it. I wasn't feeling well. It was bad judgment."

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A bigger carrot

Someone gets it. To make a difference about quality, you have to make it worthwhile for the physician.

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Teleradiology

Bob Wachter: "The growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their 'real work,' then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.

Or the country."

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The stoned 6-year old

Great case from the Stanford ER.

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Taking aim at P4P

Dr. Wes: "But perhaps a better word for this incentive program is not a reward, but a bribe to do more testing and mindless documentation. Worse, maybe this money is really a kickback scheme to reward the large hospital-owned primary care physician groups (with whom they have contracts); the same groups who already have electronic medical records and teams of gnomes who can sift through these electronically-identifiable 'quality' measures."

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Vaccine-autism link, not

Another study debunks the myth. Hear that, Eli Stone?

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Paying to remain uninsured

My opinion on individual mandates is "evolving" (as they say in politico-speak). I previously supported an individual mandate approach to universal care, as practiced in Massachusetts. At the time, it was a preferred alternative to the other solutions, such as single-payer or Medicare-for-all. The focus on personal responsibility and encouraging the consumer to contribute to health care costs appealed to me.

Seeing California's attempt fail miserably, and analyzing what's going on in Massachusetts has altered my stance. No, I still do not support single-payer. However, this scenario is ridiculous - some would rather take the penalty than pay for insurance:
Uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty -- up to half the price of a standard policy -- than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.
The government responds by capping insurance premiums, which then forces insurers to strip down coverage. This leads us down the path of saying "no", which is unfortunately unacceptable to the politicians. And so it goes.

I maintain that the focus on the uninsured is misplaced. Although important, it is not as vital as controlling costs. And that starts with primary care. As Massachusetts is finding out, the primary care system isn't ready for a bolus of newly insured patients. This paradoxically increases costs:
With a primary care shortage, many patients have to turn to subspecialists for their primary care needs, leading, in turn, to increases in health care costs while undermining the true intent of the Massachusetts Health Care Reform Plan, according to officials.
Ensure the system is ready first before tackling universal coverage. Reconcile the salary difference between specialists and generalists, and forgive all student loans for graduates who elect to practice primary care.

Without adequate primary care, universal coverage won't be worth the card it's printed on.

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How the deck is stacked against patient apologies

A doctor apologizes to the patient, and gets reamed for it:
I can’t see where the legal system has helped medicine that much. I’m certainly dismayed to work in an environment where I can’t say I’m sorry without first considering the legal ramifications of doing so. Lawyers have succeeded in sucking the notion of friendship and genuine relationship between doctor and patient entirely out of the equation.

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Universal coverage or cutting costs

Choose one or the other, because you can't have both:
Universal health care has a basic and fatal flaw, you can’t simultaneously reduce the cost of a service and increase access to it. If you have universal access, you have to find a way of paying for people to get that access, which raises costs. If you want to keep costs down you can only economize so far before you have to restrict access. Universal health care is a bit like a perpetual motion machine—it would be wonderful in theory, but it can’t actually exist in reality.

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HRC and Barack, are you listening?

AAFP: "The Massachusetts Health Care Reform Plan addresses one critical component of health care reform -- insurance coverage. Without an adequate supply of primary care physicians, however, the plan cannot guarantee timely access to care, creating a gap between coverage and actual provision of services. As a result, waiting times to see a primary care physician can amount to weeks and even months in some instances."

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MD Job Exchange



I would like to thank MD Job Exchange for their continuing sponsorship at Kevin, M.D.

The goal of MD Job Exchange (mdjobexchange.com) is to create a free, independent site which will make it easier for physicians to find great jobs and get real answers to important issues related to the practice of medicine.

The site is designed to be free in price for job seekers and free from requirements to "log-in."

Surf the site, see what real docs in your specialty have to say. Participate in the discussion forum, and take a look at the jobs.

Knowledge truly is power. Arm yourself with the right knowledge and you will be able to ask practices and hospitals the right questions to find that perfect job.

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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Wednesday, January 30, 2008

Doctoring by email

A variation on Jay Parkinson's practice, this physician eschews insurance for an internet-based approach to primary care. Wave of the future, or a niche market?

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MedBlog Power 8

01/30/2008 - 02/07/2008
Next revision: 02/07/2008



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

1) The Happy Hospitalist (2), What Would You Recommend?

2) Respectful Insolence (-), Irresponsible anti-vaccination idiocy about autism to air on ABC's "Eli Stone"

3) Health Beat (1), The Prostate as Crystal Ball

4) WhiteCoat Rants (3), Placebo Power

5) Running a hospital (-), On advertising

6) Panda Bear, MD (-), Chicken Soup For the Emergency Medicine Resident’s Soul: Inspiring Stories From the Emergency Room

7) Dr. Wes (5), In-ies or Out-ies

8) ER Stories (4), Medical Sayings, Abbreviations and Acronyms Part 2

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 mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

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1 physician: 60 inpatients

That's freakin' scary.

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EMTALA and "social admits"

Scalpel: "'Social' admits to the 'no-doc' admitting staff are usually about as welcome as a fart in an elevator. Particularly when they are unfunded midnight weekend language-barrier system-abusing complicated social admits of questionable medical necessity.

When patients like you get admitted, you tend to be challenging for the hospitalists to discharge too, so you end up receiving much more medical care than the emergency stabilization which is mandated by EMTALA. And that is both the beauty and the curse of that legislation."

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Why do some physicians embrace alternative medicine?

Partly because of cognitive dissonance and the "conversion phenomenon". #1 Dinosaur with more.

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Who's the President?

Depends on what kind of patient you ask.

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Historical medical photographs

Part of a collection stored on Flickr.



(via Healthbolt and Medgadget)

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Medicare denies too

Much has been made of Medicare's "vaunted" ability to pay on time. Well, stories like these are not uncommon:
Each time the couple submitted the bill for Terry's procedure, it was rejected. Each time, Medicare would say it wasn't the couple's primary insurer, and each time, the Sampsons would insist it was.

And so it went, month after frustrating month. Harold Sampson said he had the doctor's office resubmit the claim a half-dozen times, only to have Medicare say it wouldn't pay.
There are instances where patients have had trouble getting lab tests reimbursed by Medicare as well. Something that the "Medicare-for-all" proponents conveniently leave out. (via Dr. Wes)

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A joint a day

May be as bad as a pack of cigarettes when it comes to lung cancer.

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Template-driven EMRs

Attack of the clones: "What I see constantly when I receive EMR records from other practices (where the patient was first treated elsewhere and the treatments were not successful so they are now coming to me) is that the patients look identical. That is - I can see histories populated from checklists and quick electronic choices . . . The diseases all look the same. There is never any detail on the nuances and subtle aspects of that individual’s condition."

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The pediatric emergency department

Is it really "for the kids", or just a hospital cash cow?
If we step back from the hyperbole however, in a city the size of ours there are not that many real pediatric emergencies…or at least not enough to justify building a Pediatric Emergency Department. The traumas and critically sick children still come to the adult side (also newly constructed) and as we usually get them up to the PICU extremely quickly, what’s left is mostly urgent care and general after hours pediatrics which is, of course, what the hospital is angling for. It looks to be a stunning success and the new department daily harvests a bumper crop of essentially well children eating up a couple or three hundred bucks apiece of scarce medical resources for mostly minor, self-limiting things that are thankfully mostly relegated to the Physician Assistants.
Glad to see Panda back.

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Treating the addicted

Some physicians aren't doing them any favors:
“Some doctors, but clearly not all, cut corners. They reach for the prescription pad too readily. They under evaluate and over-prescribe. They are in too much of a hurry. Even when the vast majority of care givers to the addicted advise doctors to first consider a cold-turkey detoxification – without the benefit of additional medications,” said Dr. Len.

“We doctors write prescriptions sometimes even when they are not mandated. Insurance companies pay most of the cost and the doctor feels that he has taken action on behalf of his patient. Some have even told me, ‘I gave the patient exactly what he wanted.’”

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When you want to treat pain . . .

. . . but can't.

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Arnold Kling, his father, and how Medicare is evil

Must-read piece by Arnold Kling, on how the recent hospitalization of his father opened his eyes to some hard truths about how medicine is practice in America:
I do not expect health care to be perfect. I do not expect someone with cancer to have an enjoyable experience. I am not threatening to sue anyone, or even to suggest that the care my father received was anything other than far above average. But I do think that there were serious flaws, and that these flaws are systemic.

When Atul Gawande says that "most doctors don't like taking care of the elderly," I think he is including my father's internist and virtually every other doctor that he saw at BJC. None of the doctors touched my father with their hands. Many of them used a stethoscope. The internist looked at the cellulitis. Otherwise, they never examined him. And each specialist was only concerned with his or her particular area--the heart doctors only worried about his heart, the orthopedists only cared that the screws were in correctly, the internist only worried about the cellulitis. Nobody noticed problems with my father's veins or his skin that were caused by having too many IV's and spending too much time on his back.

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Drug reps and crack dealers?

Confessions of an ex-dealer rep: "A [drug] rep says his strategy for using free samples is much like the one 'your typical street dealer employs on the corner when he's selling crack. The first ones free, then you pay, then you're hooked.'"

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Easing the Canadian doctor shortage

Quebec seems to have found a way. Seems obvious to me.

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Cost or access: Choose one or the other

WSJ: "Liberal health-care politics is increasingly the art of the impossible: You can't make coverage 'universal' while at the same time keeping costs in check -- at least without prohibitive tax increases. Lowering cost and increasing access, in other words, are separate and irreconcilable issues."

Update:
David Catron with more. As I mentioned before, cost should supercede universal coverage. Unfortunately, reining in costs means saying "no" to patients, which is not politically feasible in an election year.

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Insidermedicine: In the Clinic - Bipolar Disorder

In the Clinic - Bipolar Disorder - Dr. James Potash, MD

Thanks to Insidermedicine for their continuing sponsorship at Kevin, M.D.

Insidermedicine (www.insidermedicine.com) is a physician-led news organization that brings daily evidence-based updates to patients, doctors and medical students. Also available in Chinese and Spanish.

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iMedExchange



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

iMedExchange is a new online physician community. Currently in Beta, they are working with a team of physician advisors who provide guidance and insight through the iMedExchange Advisor Network.

"Physicians today are highly challenged, and we need help managing our personal lives, practices and patients. iMedExchange gives me access to a community of physicians that can be my greatest resource. I joined the iMedExchange Advisor Network (iAN), 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, iAN Member, Physician Investor)

iMedExchange is looking for physicians to serve as advisors by giving feedback on new features, ideas, and community value. The time commitment is 10 minutes per week, from your own computer. In return for their time, advisors earn 100 stock options per month. Please join the community, and become an advisor, by visiting www.iMedExchange.com.

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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Tuesday, January 29, 2008

Angioplasties in "normals"

NBC's Robert Bazell: "People came in complaining of shortness of breath or chest pain, so the doctors put them into the cauterization lab and examined their vessels, then told these patients they needed an angioplasty and did it knowing full well it was unnecessary."

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Making the most of a medical meeting

Christian Sinclair with some handy hints and tips.

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Is health care a right? Depends on who you ask

52 percent of Democrats say this is the most important value that should guide health care reform, compared with only 26 percent of Independents and 12 percent of Republicans.

The contentiousness to this single question is the major reason why I suspect nothing major will get accomplished in the end.

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Is there an ethical way to make $750/hour?

Daniel Carlat discusses a recent proposal.

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Brewer: Falling HDLs due to generic statins?

Ben Brewer's WSJ column laments "pay for performance" measures that don't matter. An interesting tidbit:
. . . insurance companies have us switching prescriptions for patient with high cholesterol to generic drugs from brand-name statin drugs like Lipitor and Crestor. The expectation is that the outcome will be similar. Time will tell. I can tell from my own practice data that good cholesterol, or HDL, levels have been falling since late 2006. I think this drop off in good cholesterol may be due to the generic drugs that insurers prefer.

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"I don't like it when female ED staff cross boundaries with male physicians"

Read this and other confessions from the emergency room.

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Big CSF tubes

An ER physician wonders who fills those tubes to the top.

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Rewarding hospital frequent fliers

Aka a hospital's "customer loyalty" program.

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The concept of palliative care

It's pretty important to ensure that the patient understands what that means.

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Ketek: Next on the firing line

Newly-approved drugs are being picked off one by one.

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"We're overdue for a killer influenza pandemic"

And other uplifting Tamiflu-resistance insights.

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Should a murderer ever be allowed to practice medicine?

The case of Karl Helge Hampus and the Karolinska Institute in Sweden.

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A retail clinic chain closes

In a rush to get on the retail clinic cash cow, some are expanding too rapidly, with predictable results. It's really not the best business model to make money:
Industry experts estimate that a company can consume $300,000 to $600,000 to finance a clinic and keep it running until it reaches a break-even point of 25 to 30 patients a day.
And just wait until the first big malpractice suit is filed against them. I wouldn't buy stock in any of the clinics just yet.

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A fall from the surgical table

An unfortunate event in the OR, and the physicians in the room - two residents - are sued. Was it their fault?
Moments after undergoing surgery to replace a broken hip, an 86-year-old Dorchester woman fell from an operating room table at Boston Medical Center, causing a massive head injury that killed her a week later, her family said in a lawsuit filed yesterday.

[The patient] fell, buttocks first, through a gap in an orthopedic surgical table on Oct. 6 after a nurse removed a safety strap around her torso as medical staff prepared to transfer her to a hospital bed, according to an investigative report by the state Department of Public Health.

[The patient], who was still under anesthesia and had a breathing tube in her mouth, struck her head on the floor, fracturing her skull and causing internal bleeding, said the Health Department report. She died Oct. 13 despite a second operation that removed part of her skull to relieve pressure from the bleeding.

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Zagat surveys for doctors?

AAFP: "Choosing a doctor will always be a more complex decision than choosing a place to have dinner . . . Both doctors and patients agree that congeniality doesn't always go hand in hand with the best medical skills."

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Not every medical error is malpractice

Thanks Ted Frank for pointing out the key points in David Studdert's landmark NEJM study:
Now, even leaving aside the simple fact that not every "medical error" is actionable medical malpractice, so the Harvard study was measuring the wrong thing, perhaps Turkewitz sincerely thinks that the plaintiffs' lawyers' decision to bring a lawsuit is little better than a coin-flip in determining whether a doctor committed medical error, or that bringing a meritless suit against a doctor gives one a 28% chance of getting paid isn't a problem.
I recently re-iterated the same point in a December letter I wrote to my local paper concerning a malpractice case:
. . . Although I do not know the details of this particular case, it is important to note that unfortunate medical outcomes are not always due to physician malpractice. My sympathies go out to the ... family for the tragic turn of events, however complications occasionally happen despite following proper medical guidelines.

A recent study in the New England Journal of Medicine examined the relationship between medical errors and malpractice lawsuits. An important finding was that almost 40 percent of malpractice claims did not involve medical error.

The data from the Nashua courts support this finding, as . . . the majority of malpractice cases have been found in favor of the physician.

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Grand rounds is up

Emergiblog hosts the weekly best of the medical blogosphere.

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MedBlog Power 8

01/23/2008 - 01/30/2008
Next revision: 01/30/2008



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

1) Health Beat (2), Health Care Spending: The Basics; Spending on Physicians' Services-Do We Spend Too Much? Part II

2) The Happy Hospitalist (1), Who's Watching The Quality Puppets?

3) WhiteCoat Rants<