The WSJ writes about the sad story of Myriad Genetics, who paid $200,000 for a huge coming out party at a conference for their Alzheimer's drug.

Trouble is, the drug didn't work, so they're left with an empty, fancy booth.

Tragically comical.

Frequent NY Times contributer Sandeep Jauhar has a piece in Slate talking about night float, where interns take a 12 to 14 hour shift overnight to cross-cover the entire hospital.

Sometimes the problem of caring for another doctor's patients can lead to medical errors:

The nightmare of night float raises a central question about work limits for interns: Is it better to be cared for by a tired resident who knows your case or a rested resident who does not?

While capping resident's work hours seems like a no-brainer, the very real downsides of doing so has been underpublicized.

As for my take, night float is where one grows the stones to become a real doctor. Taking care of 50-70 patients with a minimal safety net makes you learn what sick and SICK is in a hurry.

It make be hell for interns, but a necessary evil in medical training.

(via DB)

Serial litigants, or those with a psychological need to sue.

His name contained an expletive and wasn't able to register with Verizon DSL. Verizon relented, but not without this newspaper pulling some strings.

Our car dependent society contributes to the obesity epidemic: "Recently, in a span of 3 weeks, I went from being somewhat out of shape to being reasonably in shape. I lost about 1.5 kilos, my posture improved, my skin got healthier. What exercise regime did I follow to accomplish this? I stayed in a rental house in the Netherlands for 3 weeks. In other words, I carried lots of stuff around and rode a bicycle about 10 km a day, just in the normal course of living."

(via Ezra Klein)

In the Clinic - Dr. Howard Hodis, MD, Discusses the Prevention of Heart Disease

Stanley Feld has been doing a series on why physicians are slow to adopt electronic records.

The common perception is that they are expensive or ludditic doctors are desperate to cling to paper charts.

The main problem is that the current crop of EHRs are simply not ready for prime time. I recently read a story where doctors have their staff print out a patient's electronic record for every encounter, then handwrite a note and have the staff scan it back into the computer.

Furthermore, the EHR learning curve ranges from a few weeks to a months, depending on how computer literate you are. When revenue is based on number of patients seen, the loss of productivity, compounded with the cost of the EHR, is financially crippling.

What a deal.

If widespread electronic record adoption is to occur, the following needs to happen:

i) EHRs need to make the doctor's life measurably easier, and accomplish what the physician currently does in less time

ii) the cost and loss of productivity during the startup period needs to be reimbursed 100%

Until those conditions are met, the dream of universal electronic records will never be realized.

Update:
Someone e-mailed asking me for my solution. Here's it is.

Implement open-source VistA in every physician practice in the country, free of charge. This will also solve the compatibility problems caused by hundreds of EHRs permeating the market that don't talk to each other.

Give a stipend to each practice, equal to one month's average office revenue, to compensate for productivity loss during the transition.

Voila, problem solved.

Why patients so eager to hate the physician profession: "I suspect the payment system has something to do with it. When patients don’t know what we charge for things (we are not allowed to disclose our fee schedules), they assume we are milking the system for all it’s worth. The fact that the majority of transaction happens below the surface devalues the visit."

Nice post from Dr. Rob. I'd like to add that the media tends to hype cases that portray physicians negatively - it sells more papers. Stories where patients are satisfied with their care and happy with their physicians make for boring headlines.

That being said, doctors have the come to grips with the better informed patients of today. The internet will be the primary source of consumer health information, and we need to better handle patients who show up with preconceived, self-researched notions of their condition.

Arnold Kling argues that the administrative savings from a single-payer system is minimal and superficial:

After [getting rid of private insurance administrators], costs might be less than the existing system. By a small amount. For a short time. But innovation in health care management and administration would slow to a crawl. Health care providers would need permission from Washington to try anything new. In the long run, administrative costs will be higher than they would have been under private health insurance.

In the short run, getting rid of competition and installing a monopoly lowers overhead. In the long run, it's not so brilliant.

Aside from the supposed savings from administrative costs, the main problem with a single-payer system is that there is no recourse for physicians to turn to should things sour. With the recent Medicare debacle, doctors threatened to drop Medicare patients and successfully pressured Congress to reverse a pay cut.

With a single-payer/Medicare-for-all system, physicians no longer have that leverage. Of course, health wonks would love nothing more than powerless physicians.

What puzzles me is why some within the medical profession are willing to give that up.

Theresa Chan, a family physician who blogs at Rural Doctoring, will be Dr. A's guest.

Here's how to listen.

A patient posts pictures on Flickr. Clinical Cases analyzes the case.

The sad story of a mother who wanted to exact revenge on her obstetrician.

The patient comes out ahead in many cases: "All patients who suffer a treatment injury caused by medical care are eligible for no-fault, government funded, compensation (with no need to prove negligence). Claims are usually decided within a matter of days, and the package of care includes financial compensation as well as free treatment, rehabilitation, home help, childcare, and so on."

Contrast that to what happens here, where the patient has to endure the legal process spanning several years, often ending up with nothing.

A NYC physician spends $10,000 . . . for his dog's "Bark Mitzvah".

The Gone Wild series continues.

7/30/2008 - 8/6/2008
Next revision: 8/6/2008

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

1) Rural Doctoring (1): Rural Doctor goes on vacation. Since physicians are generally paid by productivity, a vacation isn't really one when everything's considered.

2) The Covert Rationing Blog (4): Two-tier dermatology? Leave the physicians alone, says DrRich as he responds to the recent NY Times piece.

3) WhiteCoat Rants (6): WhiteCoat gets a much-needed nap during a night shift. Sometimes the strangest dreams come true.

4) Health Beat (2): Health policy isn't the only thing Maggie Mahar and Niko Karvounis talk about. One interesting diversion is their take on the controversial medical marijuana issue.

5) Musings of a Distractible Mind (-): Dr. Rob often has insightful and witty takes on all things health care, like this observation on why Pfizer is partnering with prison guards to promote Lyrica.

6) WSJ Health Blog (-): This is the what you get when you have a full-time journalist and editor dedicated to health blogging, backed by the clout of the WSJ. Unparalleled access behind the scenes of relevant health topics, like scrapping the fee-for-service system and how hard it is for retail clinics to make money. It has a large following, and the debate in the comments is often contentious.

7) Aggravated DocSurg (-): Surgeons can have pretty snarky takes. This post on capping resident work hours rings true, expressed in Aggravated DocSurg's unique style.

8) Mothers in Medicine (8): A look at medicine through a mother's eye. The blog recently had their first "topic day": stories from labor and delivery.

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.

If I Had - Joint Symptoms Indicative of Arthritis - Dr. Teresa Brady, PhD

He takes exception to the hysteria about two-tier dermatology. A nice retort to the piece:

Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming retainer practitioners.

Well said.

I'm forced to cut 2-3 rings a year off swollen fingers. Patients are none to happy that that prospect. Here's a method I'm going to try before reaching for the ring cutter.

Two major organizations duke it out regarding routine EKGs for kids taking ADHD medication.

There is no doubt that the AHA's guideline will win out. Given the choice between testing and not, the decision to test will always win in court and with the public. Especially with the clout of the AHA behind it.

btw - I like how Dr. Farrago calls the ubiquitous Steven Nissen the "Britney Spears" of medicine.

How to answer the "why do you want to come here" question that is inevitable in all medical school applications.

It's easier if you actually like your patients.

Sounds about right: "It's a perfect storm of demand for medical care."

The effectiveness of any single payer system depends on how it's funded. Will the government step up to the plate?

What happens at the VA is a useful predictor of how the government will act in any federally-based reform plan.

It certainly looks good on paper: "Managers of on-site centers such as Toyota's make a variety of bold claims. Rosenbluth says every dollar invested in setting up a clinic will return $3 to $5, even though on-site doctors spend an average of 20 minutes with each patient—more than double the national average for primary-care physicians."

This trend is likely to grow, as corporations grapple with exploding health care costs. Eventually however, the costs of these clinics will increase as well. At what point will the company start to skimp on these services, which are entirely under their control?

Doctors and patients often lament the lack of time they spend with each other. An interesting study suggests that it doesn't matter:

In five studies conducted in the United Kingdom, doctors did not discuss more problems, prescribe more drugs, run more tests, make more referrals or do more examinations when they had a few additional minutes with patients.

More importantly, patients did not feel more satisfied when they spent more time with the physician.

There is a subset of the population who want quick, brief interactions with their physicians. These typically are those who are younger and healthier.

Doctors who spend less face to face time with patients are more often on schedule and on time. Some patients value that punctualness and it shouldn't be discounted.

Try Amazon.com. (via kottke)

That's sad commentary on the primary care shortage.

Matthew Holt opines that the primary care crisis will hasten the outsourcing of medical care:

In fact, the result of the primary care crisis may not be inspired reform. it may instead just end up causing globalization and technology outsourcing to come into physicians' lives. Just like it has to auto workers, steel workers and call center clerks.

That is no doubt a possibility. However, the choice will be decided by patients. If they demand American-trained physician-level primary care, then they'll push back - just as they did against managed care.

If not, well, I'll be looking for another line of work soon.

The Kaiser Family Foundation held a panel discussion this afternoon discussing the role of blogging in health policy and reporting. It's quite good and if you have a bit of time to spare, well worth seeing.

Reader Takes is a regular feature where selected op-ed style pieces from the audience at Kevin, M.D. will be published on the blog.

Posts are between 500 and 600 words in length, and can argue any opinion related to medicine and health care.

Original articles that are provocative, well-written, free of grammatical or spelling errors, and generally follow these guidelines are preferred.

Once a reader take is published, it will remain at the top of the blog above the fold for one day. A link to the author's book, blog, or website will be included.

Kevin, M.D. receives in excess of 10,000 visits daily, and is regularly read by major media outlets.

The piece will remain exclusive to Kevin, M.D. and may not be republished elsewhere.

If you are interested in submitting a take for consideration, please contact me.

In the Clinic - Dr. Lon Schneider, MD, Discusses the Treatment of Alzheimer's Disease

Patient privacy advocates: "Where there’s a push to make medical records electronic, there’s a worried patient-privacy advocate."

An odd advertising partnership to say the least.

Charlie Baker hits the nail on the head, on why costs are absent from the political debate: "It's easier to talk about doing more things for more people than it is to talk about taking costs out of the system."

Most proposals focus on reforming the physician payment system, and turning back the clock to embrace capitation.

That sounds great in theory, and I bet many generalist physicians will go for it, but the real challenge is to convince patients to remove the foul taste of capitation from their mouths.

Edwin Leap hosts the weekly best of the medical blogosphere.

Nick Genes announced that he will be giving up the day-to-day management of the weekly series.

We all owe a debt of gratitude to Nick's effort to maintain and publicize the series on Medscape. As he states, major media has finally caught on the the medical blogging phenomenon, and that is in no small part to the visibility and exposure that Grand Rounds brought.

Thanks Nick for all your work.

A reason why people with routine, chronic illness go to the ED instead: "You're sick, you're hurt, you can't get in to see your family doctor, you don't have a family doctor - they come in . . . People being people, and water being water, they follow the path of least resistance."

Which goes to show that improving primary care access will be an effective way to relieve emergency room overcrowding.

He advocates a Medicare-for-all system, which would have made what he did for himself impossible for the average patient:

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

The United States is the one of the few countries in the world where Ted Kennedy could have received such superlative specialist care. I hope those on the left recognize that, and give some credit where it's due.

Relations between doctors and patients are at an all-time low: "The reasons for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive."

Republicans try to lure physicians back to the fold after their shameful performance in the Medicare bill debacle.

It comes a little too late, in my view. Actions speak louder than words. When the chips were down, health insurers clearly took precedence over physicians.

A healthy rant from the Daily Kos, which is accurate in saying that universal coverage will push primary care over a cliff:

Add a new national health insurance scheme or mandate—without addressing the dwindling supply of primary care docs—and things may quickly collapse. The pent-up demand for medical care among the uninsured and underinsured is huge. We have absolutely no reserve capacity to serve them.

Most of the essay is similar to what's been discussed here, but the take on academic medicine caught my eye:

. . . the very culture of university hospitals and medical schools is profoundly hostile to primary care. The high priests of academic medicine are brilliant subspecialists, innovative surgeons and similar technically oriented superstars, hailed for their ability to bring research money and publicity to the medical center. Primary care by contrast is habitually denigrated and disrespected. The lip-curling sarcasm directed at the "LMD" (local medical doctor), the withering contempt for primary care in the trenches, has to be seen to be believed. Medical students "bake" for four years in this hot-house atmosphere. Small wonder so few choose primary care. Add in the vast disparity in income, and it's a miracle anyone does.

Increasing the primary care numbers starts with respect for the work we do. Judging from what I read here, the hostility medical students have for generalist medicine starts at the very beginning.

If our colleagues don't value primary care, how can we expect the public and politicians to?

. . . doctors that is. Over 20 percent of Palm Beach County's physicians are going bare, without malpractice insurance.

This is a direct result of a toxic malpractice climate in Florida. You reap what you sow, and now patients lose as doctors simply declare bankruptcy when sued.

It is imperative that any semblance of reform include balance billing: "Allowing balance billing would make it far less likely any physicians would turn down Medicare and it would greatly decrease the pressure on the government to keep reimbursement levels up."

Medpolitics is a new blog from the founders of Medgadget, giving physicians a voice in the political issues surrounding medicine.

It is imperative that physicians take a front and center seat in upcoming health care reform. Nothing less than the future of the entire medical profession is at stake.

I generally support the guidelines in the USPSTF, and they are fairly conservative. However, convincing the public that less screening is better is a tough sell. All it takes is one media-hyped "missed diagnosis" story to undo all the evidence that physicians try to teach.

So, I don't think this guy will get very far with his views:

For adults, we can debate the Pap smear for women—not whether but how often. Aside from that, there's no reason for any routine screening, including an annual physical examination. Go to the physician whenever you have a question—and wouldn't it be nice if you had a physician who was rewarded for taking the time to answer?

Not always easy to do: "Surgeons, he said, 'have very strong egos and by nature are not collaborative,' and it requires a firm hand to get them to 'fly in formation.'

'What you have to do is to switch styles when you go outside of the department and deal with nonsurgeons. That is very difficult to do.'"

Maybe they're the only ones making money playing bed-shifting games:

Hey - these authors are from the University of Pennsylvania and Penn’s profits were up by 6.5% the last fiscal year - the best performance since the Pennsylvania Health Care Cost Containment Council started keeping records in 1995. Compare this to the fact that one quarter of Western Pennsylvania’s hospitals lost money in the last fiscal year. Maybe they’re on to something. Maybe Penn needs another federal audit to make sure it isn’t committing any more health care fraud.

A look at his online legacy.

Nurses: "In the ever worsening financial stresses being forced upon our system, one can see why nurses can feel overly burdened by very time consuming and needy patients while also trying to maintain a picture perfect paper trail of documentation that has overwhelmed their profession to much the same degree as physicians."

It's a different beast altogether: "We rely on online references such as UpToDate and telephone consultations with UCSF perinatologists to guide us, but formal referrals are not pursued if the patient is doing well."

Stanley Feld summarizes the reasons, and they are essentially similar to what I've mentioned before.

It comes down to financial incentives, and so far, there are none for physicians to go forward.

The importance of quiet: "I had the feeling that we make it LOOK easy 99 times out of 100, so people FORGET that it's a LIFE AND DEATH moment up there, getting the airway. It looks easy most of the time, and after a couple of thousand, yes, most of the time it's a comfortable procedure, but there's also nothing more important than that precarious moment right at that moment."

See how it has evolved over the years, and what you get to take home as souvenirs.

It comes in handy during this complex hand injury case.

Sounds pretty cush.

There's something very wrong with this: "Madeira Therapeutics . . . is formulating a liquid statin for children that will be sold in either grape, cherry or bubblegum flavor."

Buckeye Surgeon with a moving post on recent case:

I think we all carry our own lesions with us throughout life, whether it resides on our back, or our leg, or deep within the recesses of our hearts. We all have them. There's no shame in that. And it's a good thing to know that the burden can be lessened the moment we decide to reveal it, the moment we decide we don't want to endure it alone anymore....

The beginning of the end of medical education: "I fear that the "professional educators" are pushing medical education over a cliff, from where it may never recover."

Remember, there are no work-hour restrictions in the real world.

A physiology professor rants on physicians, and causes quite a stir. Is his apology acceptable, or was it forced due to the threat of exposing his identity?

A study last year showed that the wait to see a dermatologist was significantly shorter if the need was cosmetic. When physician payment is tightly regulated, you can expect nothing less:

Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.

Two Reader Takes this weekend. Each dealing with health care reform, one from the left and the other from the right.

Enjoy. Regular blogging will resume Monday.

The following is a reader take by Half MD.

Archaeologists this week have discovered an ancient Indian enclave in what is now rural Mississippi. Called the Click Creek Indians -- this particular organization seems to have been wiped out many hundreds of years ago, but left behind a vast library with which scientists were able to piece together their final history. This tribe was well advanced and used a written language etched into leather and papyrus to keep track of the days' events.

This society believed in the transportation of currency and used animal skins and shells to purchase goods and services. To have wealth meant to accumulate animal body parts. At the highest rungs of the economic ladder people would display their body parts within their homes. This practice of exhibiting animal parts was so popular that it continues to this day amongst the modern inhabitants of Mississippi.

Within this location there lived a witch doctor by the name of Kisni who had spent many years studying the ancient arts of herbalism and spiritual healing. By crushing together mushrooms he could cure gangrene. His meditations could relieve headaches. And his various potions could alleviate all manner of GI upset. He was the best in the region and his skill commanded a hefty fee.

One day a local farmer by the name of Stimu visited the witch doctor in hopes of finding a cure for his sore throat. Kisni agreed to take the case, examined the man's neck, and said that he could heal it at the costs of three shells. Stimu recoiled in anger and stated that he shouldn't have to pay the fee. "Witchcraft is a right that everyone deserves! You are just being greedy with something that's so important." He then stormed out of the hut and gathered his neighbors.

He convinced them that knowledge about herbs and potions should be freely available to everyone and that the people who supply the mushrooms and plants were in a conspiracy to drive up prices. Together they sought out the nation's warlord to force the witch doctor to treat the inhabitants for free. The warlord listened to stories of people who have been turned away by the witch doctor. He heard of a child who was forced to live with a splinter in his hand because his parents could not provide a raccoon's tale. He heard of a man who almost died of heat exhaustion because he could not afford a cooling elixir. The warlord grabbed his fighting stick and shouted, "I'll force the witch doctor to give away his witchcraft for free. If he doesn't, I'll whoop him."

Together they banded and preceded to the witch doctor's hut. The warlord ordered Kisni to provide free care to everyone, regardless of ability to pay. The doctor replied, "I spent so many thousands of shells and skins trying to earn my education. I simply cannot give away witchcraft for free. I'll be forced to leave this region if you continue with your demands."

When it finally became apparent that the witch doctor would not be able to live under the warlord's demands, he packed his things up and fled to live with a nearby tribe. Eventually the Click Creek Indians succumbed to infection. Without the witch doctor's presence to heal them, they all died from disease. All that's left of them are their leather and papyrus writings.

Half MD is a medical student that blogs at Half MD.com.

The following is a reader take by Malinda Markowitz.

If you wonder why Republican campaign strategists are worried about their party's vulnerability on health care, consider the story of Leslie Elder of West Palm Beach, Fl..

"We had major medical health insurance, and than I was diagnosed with breast cancer in 1987. After a radical mastectomy, I was again diagnosed with breast cancer and another radical mastectomy in 1992. Left with large unpaid balances and triple the premiums we were forced to drop the insurance in 2003," Leslie wrote in a recent message to the National Nurses Organizing Committee/California Nurses Association.

"In 2005 I was diagnosed with kidney cancer resulting in the removal of one completely and part of the other. I had the help of a family member and paid almost $70,000 for the two surgeries."

"The horror now is that I won't go back for check ups, for fear of hearing those words again 'you have cancer, and you have no coverage'. I still work so I cannot get Medicare, and the insurance is unaffordable."

Sadly, Leslie and her family are not alone. A report cited in the Wall Street Journal June 26 found that 20 percent of Americans said they'd put off medical treatment in the preceding year, nearly 70 percent of them due to cost.

She may also be among those identified by a July NPR/Kaiser Family Foundation/Harvard School of Public Health survey of the battleground states, Florida and Ohio.

That survey found 28 percent of Floridians and one-fourth of Ohioans say they or a family member had problems paying medical bills the past year. Among that group, more than half self-ration care -- delaying or foregoing needed medical treatment or dental care, not filling prescriptions, cutting pills in half or skipping doses.

What makes the health care crisis worse is how it compounds the overall economic plight for American families today. The Kaiser Health Tracking Poll in June recorded that six in 10 adults cite a "serious" financial problem, led by gas prices, low paying jobs, and paying for health care.

It has not escaped many voters that their health and financial ship of state has hit rough waters under the Bush administration. The Journal report, for example, noted relative "stability" in patient access to care from 1997 to 2003 and a massive leap in insecurity since. During that same period, the number of uninsured and underinsured Americans, insurance premiums, and drug prices, have all skyrocketed.

Against this backdrop, Sen. John McCain's health plan closely resembles the policies of the present administration. He's proposing tax credits of $2,500 for individuals and $5,000 for families to help more people buy insurance.

But that's less than half the current average premium costs. And, McCain offers nothing to control the costs of those skyrocketing premiums except a dubious reliance on competition in an insurance industry that does not compete on quality or access, but by cutting costs mainly through denying care or dumping people when they get sick.

McCain wants to further deregulate an already poorly regulated industry, and eliminate employers' health insurance tax deduction, a worrisome incentive for employers to stop offering health coverage. The inevitable result -- more costs and health risks shifted on to families like Leslie's.

By contrast, Sen. Barack Obama's health plan would provide subsidies for those who can't afford the current pricy plans, and take a tougher stand against insurance and drug company practices. He wants to permit Americans to buy cheaper medications from other countries, repeal the Bush administration ban on the government using its bulk purchasing power to negotiate lower prices from drug companies, and prohibit insurers from denying coverage to people with pre-existing conditions.

Though a step well beyond the McCain plan and the dismal indifference of the Bush years, the Obama plan does not go far enough either. It still leaves too much control over our health in the hands of the insurance giants.

Leslie has another idea, "We need HR 676." That's the bill that would essentially improve Medicare and extend it to all Americans.

The need could not be greater. A Commonwealth Fund study July 17 found that U.S. has plunged to last among major industrial nations in preventing deaths through timely and effective medical care even though we spends more than twice as much per person on healthcare.

What's the central difference? All those other countries have a national healthcare system (like our VA healthcare system) or a single payer system (like Medicare), and they don't have insurance companies determining when or if you should receive care.

HR 676 has more co-sponsors than any health reform in Congress and millions of Americans who know it is the most effective solution to our health care crisis. We need a more humane health care system and a sharp break from the abysmal policies of the present. Families like Leslie's and the rest of us deserve nothing less.

Malinda Markowitz, RN is co-president of the National Nurses Organizing Committee/California Nurses Association.

David Catron is riled up, responding to the recent Slate piece: "The authors of this disgraceful piece of agitprop would have their readers believe that the people who run hospitals deliberately allow people to languish in their ERs for financial gain. The suggestion is not merely slanderous. It is absurd on its face.

I have worked in hospital finance (at institutions large and small) for more than two decades and have never met an administrator or finance person (not one) to whom such an idea would even occur. Where I have worked, suggesting such a policy would get you fired."

Bob Wachter explains how Knol and Wikipedia will soon be a disrupter to traditional medical literature.

Shadowfax, you make it sound so easy: "But when you underfund primary care, create a system which reward procedures and skimps on cognitive services, freeze Medicare reimbursements on top of it all, it is predictable and unsurprising that the more time- and resource-intensive acute illnesses get shunted to the ER. While it's good for my business, it is decidedly not good for patients, who deserve to be cared for when possible by their personal doctors in a setting where they can devote sufficient time to their care, and it is not good for the country, because ER care is incomplete, fragmented, and expensive.

Memo to Congress: fix primary care, and much of the ER crisis will be alleviated, too."

In case you're looking for other ways to keep up with Kevin, M.D., my posts are now broadcast on Twitter.

Of course, you can always subscribe using a variety of newsreaders.

In the Clinic - Dr. Cherry Wongtrakool, MD, Discusses Patterns of Restrictive Lung Disease on Spirometry

Uh, there are primary care physicians all over the country who have come to the same conclusion.

DrRich: "We in America (citizens, the government, and the insurers) refuse to acknowledge that there are limits to what we should expect from our healthcare system. We expect to receive any bit of healthcare that offers even a possibility of benefit, even if that benefit is likely to be marginal or transient. We expect our researchers to work day and night to cure every disease, no matter how rare, and we become indignant when progress does not seem rapid enough for our particular disease; indeed, death itself is merely a manifestation of insufficient research. In other words, where healthcare is concerned, there are and can be no limits."

What's up with that? Here's the closest you'll come to experiencing a D&C over the computer.

. . . or not.

Did his tumor return? Why does he look so frail? Surgeon Orac with detailed speculation.

Peter Bach, in a NY Times op-ed: "Without changes to the way Medicare pays doctors, the fights in Congress over raising or lowering payment rates will continue. And doctors will still have no financial incentive to do what is most important: spend more time with their patients."

Two emergency physicians stir things up: "Potentially, those that profit more from boarding, particularly in poorer communities with high numbers of uninsured and Medicaid patients. Imagine you run a hospital. There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits. The second source is E.R. patients, who are more likely to be uninsured or have pittance-paying Medicaid and less likely to need high-margin procedures. Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money."

Emergiblog responds.

With taxpayers on the hook.

The MySpace/Facebook generation is getting close to graduating medical school.

Boy, are they going to regret how Google's indexed their names when they start practicing medicine. This is the future of American medicine:

University of Florida researchers found several such items of interest when they trolled the Facebook pages of the school’s medical students.

Researchers found shots of future doctors grabbing their breasts and crotches or posing with a dead animal. They also found many photos of students drinking heavily.

When the treatment may end a promising football player's career: "My decision about how to intervene could very well end his football career. If he loses weight, he won’t be competitive against 280 lb. linemen in college. If he sits out his senior year to get his cholesterol and hypertension in line, he won’t get noticed by colleges."

I think Dr. Rob says it best in the comments of this brilliant post: "EXACTLY why I don't do inpatient any more."

I can't imagine doing this, and then driving back and seeing 20+ patients in the office.

It's already happening.

This new study suggests yes:

"The blogging community has made an effort to set standards for medical bloggers, but unfortunately, professional organizations and medical educators haven’t come out with rules for handling the new medium . . . Medical blogs are a great opportunity to learn about the health care system, but they need to know some bloggers have unprofessional conduct, although that doesn’t represent the medical profession as a whole. The issue is the risk of losing patient trust. We want to maintain that."

I'm glad that physician blogs are inching their way into the medical literature. Good to see them finally join the party. Better late than never my friends.

Two issues seem to be of concern: blogging about patients and product endorsement.

I agree that physician blogs that write about patients do need to be held to a higher than normal blog standard. Mainstream media and the academic medical community is just starting the grasp the power of medical blogging, and doesn't quite know what to make of it.

It seems that medical blogging's greatest strength - giving an unfettered view "behind the scenes" of medicine - is its biggest controversy. I simply choose to stay away from this by not writing about patients, but I am aware that the most interesting medical blogs are those that speak freeing about patient encounters.

Regarding advertising, it's commonplace on blogs. Should physician blogs be required to disclose conflicts of interest? Should blogs be held to the same standard as medical journals?

I say no. It's just a blog, lighten up. But for those who care about such things, my policy regarding product endorsements has always been contained in my disclaimer, written in no uncertain terms:

THE INCLUSION OF THIRD PARTY ADVERTISEMENTS DOES NOT CONSTITUTE AN ENDORSEMENT, GUARANTEE, WARRANTY, OR RECOMMENDATION OF, AND THE AUTHOR MAKES NO REPRESENTATIONS AND/OR WARRANTIES ABOUT, ANY PRODUCT OR SERVICE CONTAINED THEREIN.

There you have it.

M.D.O.D.: "Who or what is to blame: the government's and administrators' ill-conceived policy decisions; the doctors who have rolled over and allowed these policies to infest medicine; the irresponsible and unreasonable patients who demand perfect care for free; or the culture that says irresponsibility and unreasonableness is acceptable?"

Restrictions on work hours don't exist when you're an attending. Will today's residents be ready?

So you're a general surgery intern. You'll be working 80 hour weeks (and possibly less than 60 hrs if further reforms are implemented). Post call, you'll be eating breakfast and reading the newspaper in the comforts of your own home by 8am, irrespective of any work that remains to be done on the patients you cared for over the night . . . Will you be ready for the sort of weekend I just described when you're an attending surgeon?